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Washington Apple Health (Medicaid)Sleep CentersBilling GuideFebruary 20, 2019Every effort has been made to ensure this guide’s accuracy. If an actual or apparent conflict between thisdocument and an agency rule arises, the agency rules apply.
Sleep CentersAbout this guide*This publication takes effect February 20, 2019. It is a compilation taken from several guidesdetailing information on Sleep Studies.HCA is committed to providing equal access to our services. If you need an accommodation orrequire documents in another format, please call 1-800-562-3022. People who have hearing orspeech disabilities, please call 711 for relay services.Washington Apple Health means the public health insurance programs for eligibleWashington residents. Washington Apple Health is the name used in WashingtonState for Medicaid, the children's health insurance program (CHIP), and stateonly funded health care programs. Washington Apple Health is administered bythe Washington State Health Care Authority.Refer also to the agency’s ProviderOne Billing and Resource Guide for additional informationabout agency billing.What has changed?Subject*ChangeReason for ChangeEntire documentGeneral housekeepingTo improve clarity and usabilityEquipment andsuppliesChanged the Prescribinginformation section, clarifying thatrespiratory supplies and equipmentdo not require a physician’ssignature/co-signature when beingorderedTo clarify Medicaid Programpolicy changes, and the orderingof Home Health services,including medical supplies andequipmentThis publication is a billing instruction.2
Sleep CentersWhere can I download agency forms?To download an agency provider form, go to HCA’s Billers and provider’s webpage, selectForms & publications. Type the HCA form number into the Search box as shown below(Example: 13-835).How can I get agency provider documents?To download and print agency provider notices and billing guides, go to the agency’s Providerbilling guides and fee schedules website.Copyright disclosureCurrent Procedural Terminology (CPT) copyright 2018 AmericanMedical Association (AMA). All rights reserved. CPT is aregistered trademark of the American Medical Association.Fee schedules, relative value units, conversion factors and/orrelated components are not assigned by the AMA, are not part ofCPT, and the AMA is not recommending their use. The AMA doesnot directly or indirectly practice medicine or dispense medicalservices. The AMA assumes no liability for data contained or notcontained herein.3
Sleep CentersTable of ContentsAbout this guide .2What has changed? .2Where can I download agency forms? .3How can I get agency provider documents? .3Resources Available .7Definitions .8About the Program .11What is the purpose of the Sleep Centers and Medicine program? .11When does the agency pay for sleep center and sleep medicine related care? .11Becoming an agency-approved Center of Excellence (COE).12Client Eligibility .13How do I verify a client’s eligibility? .13Are clients enrolled in an agency-contracted managed care organization (MCO)eligible? .14Managed care enrollment .15Behavioral Health Organization (BHO) .15Apple Health – Changes for January 1, 2019 .16Integrated managed care .17Integrated managed care regions .17Integrated Apple Health Foster Care (AHFC) .18Fee-for-service Apple Health Foster Care .18Provider Requirements .19What are the general responsibilities of a sleep center/sleep medicine provider? .19Are providers responsible to verify a client’s coverage? .19What are the client’s rights to health care decisions? .20Coverage .21What are the coverage criteria for sleep centers and sleep medicine related services? .21Sleep medicine testing (sleep apnea) .21Sleep center physician consultations and referral for cognitive behavioral therapy(CBT) .24Equipment and Supplies .24Replacement of bi-level RAD equipment and supplies .27Continuous positive airway pressure (CPAP) and supplies.28Clinical criteria.28Use of RAD instead of CPAP .29Prior authorization for a CPAP device.294
Sleep CentersRental and purchase of a CPAP device.30Replacement of CPAP equipment and supplies.30Mandibular advancement devices (oral appliances) .31Clinical criteria.31Prior authorization .32Exclusions .32Billing .33Payment.33Pulse oximetry .33Clinical criteria for standard oximeters.33Clinical criteria for enhanced oximeters .34Coverage Table for Equipment and Supplies .35Continuous positive airway pressure system (CPAP) coverage table .36Respiratory assist devices coverage .40Miscellaneous .43Authorization.45What are the general authorization requirements?.45What is prior authorization (PA)? .46What are the criteria for PA? .46What is the PA process? .47Is PA required for repairs to client-owned equipment? .48What is expedited prior authorization (EPA)? .48What are the EPA criteria? .49What is the EPA process? .49Expedited prior authorization (EPA) criteria table .50What is a limitation extension (LE)? .50What are the LE criteria? .50What is the LE process? .51Billing .52What are the general billing requirements? .52Billing with authorization numbers .52Is information available to bill for clients eligible for both Medicare and Medicaid? .52How does the agency handle third-party liability coverage? .53How do I bill claims electronically? .53Billing for Services .54Billing for Supplies .55Add-on codes .56By report .56Codes for unlisted procedures .56Diagnosis codes .56Discontinued codes .57National correct coding initiative.57Medically Unlikely Edits (MUEs) .575
Sleep CentersProcedure codes .586
Sleep CentersResources AvailableTopicContact InformationHow do I obtain priorauthorization or a limitationextension?For all requests for prior authorization or limitation extensions,both these forms are required: A completed, TYPED General Information forAuthorization form, HCA 13-835. This request formmust be the initial page when you submit your request.See Where can I download agency forms?Fax your request to: 866-668-1214.How do I check on the status of a request for prior authorization or limitationextension?Call 800-562-3022 and select the topicCall 800-562-3022, extension 15471How do I get answers forbilling questions?Call 800-562-3022 and ask for the billing extension.How do I obtain informationregarding the Sleep Centersand Sleep MedicineProgram?Do one of the following: Contact the Billers and Providers "contact us" webpageWho do I contact if I have areimbursement question?Cost Reimbursement AnalystProfessional ReimbursementPO Box 45510Olympia, WA 98504-5510 Contact the Sleep Centers and Sleep Medicine programmanager at:Division of Health Care Services/CQCTHealth Care AuthorityP.O Box 45506Olympia, WA 98504-55067
Sleep CentersDefinitionsThis section defines terms and abbreviations, including acronyms, used in this billing guide.Refer to Chapter 182-500 WAC for a complete list of definitions for Washington Apple Health.Acquisition cost (AC) – The cost of an itemexcluding shipping, handling, and anyapplicable taxes.American Academy of Sleep Medicine(AASM) - The only professional societydedicated exclusively to the medicalsubspecialty of sleep medicine. AASM setsstandards and promotes excellence in healthcare, education, and research. Membersspecialize in studying, diagnosing, andtreating disorders of sleep and daytimealertness such as insomnia, narcolepsy, andobstructive sleep apnea.Acute care – Care provided for clients whoare not medically stable or have not attaineda satisfactory level of rehabilitation. Theseclients require frequent monitoring by ahealth care professional in order to maintaintheir health status.Bundled services – Services integral to themajor procedures that are included in the feefor the major procedure. Bundled servicesare not reimbursed separately.Add-on procedure(s) – Secondaryprocedure(s) performed in addition toanother procedure.Apnea – The cessation of airflow for at leastten secondsCentral sleep apnea (CSA) – Is defined asmeeting all the following criteria:Apnea-hypopnea index (AHI) – Theaverage number of episodes of apnea andhypopnea per hour of sleep without the useof a positive airway pressure device. Forpurposes of this chapter, respiratory effortrelated arousals (RERAs) are not included inthe calculation. Assignment – A process in which a doctoror supplier agrees to accept the Medicareprogram’s payment as payment in full,except for specific deductible andcoinsurance amounts required of the patient.An apnea-hypopnea index (AHI) greaterthan or equal to 5.Central apneas/hypopneas greater than50% of the total apneas/hypopneas.Central apneas or hypopneas greaterthan or equal to 5 times per hour.Symptoms of either excessive sleepinessor disrupted sleep.Code of federal regulations (CFR) – Acodification of the general and permanentrules published in the federal register by theexecutive departments and agencies of thefederal government.8
Sleep Centersand hypopnea per hour of sleep without theuse of a positive airway pressure device.Complex Sleep Apnea (CompSA) – Aform of central apnea specifically identifiedby the persistence or emergence of centralapneas or hypopneas, upon exposure toCPAP or a bi-level respiratory assist devicewithout a back-up rate feature, whenobstructive events have disappeared. Theseclients have predominantly obstructive ormixed apneas during the diagnostic sleepstudy occurring at greater than or equal tofive times per hour. With use of a CPAP orbi-level respiratory assist device without aback-up rate feature, the client shows apattern of apneas and hypopneas that meetsthe definition of central sleep apnea (CSA).Informed consent – Where an individualconsents to a procedure after the providerwho obtained a properly completed consentform has done all of the following:(1) Disclosed and discussed the client’sdiagnosis(2) Offered the client an opportunity to askquestions about the procedure and torequest information in writing(3) Given the client a copy of the consentform(4) Communicated effectively using anylanguage interpretation or specialcommunication device necessary per 42C.F.R. Chapter IV 441.257(5) Given the client oral information aboutall of the following:a. The client’s right to not obtain theprocedure, including potential risks,benefits, and the consequences ofnot obtaining the procedureb. Alternatives to the procedureincluding potential risks, benefits,and consequencesc. The procedure itself, includingpotential risks, benefits, andconsequencesContinuous positive airway pressure(CPAP)- A single-level device whichdelivers a constant level of positive airpressure (within a single respiratory cycle)by way of tubing and an interface to assistspontaneous respiratory efforts andsupplement the volume of inspired air intothe lungs.Core provider agreement" or "CPA" The basic contract the agency holds withproviders serving medical assistance clients.Healthcare Common Procedure CodingSystem (HCPCS) - Standardized codingsystem that is used primarily to identifyproducts, supplies, and services not includedin the CPT codes, such as ambulanceservices and durable medical equipment,prosthetics, orthotics, and supplies(DMEPOS) when used outside a physician'soffice."Multiple sleep latency test" or "MSLT"- A sleep disorder diagnostic tool used tomeasure the time elapsed from the start of adaytime nap period to the first signs ofsleep, called sleep latency. The MSLT isused extensively to test for narcolepsy, todistinguish between physical tiredness andtrue excessive daytime sleepiness, or toassess whether treatments for breathingdisorders are working.Hypopnea – A temporary reduction ofairflow lasting at least ten seconds andaccompanied with a 30% reduction inthoracoabdominal movement or airflow ascompared to baseline, and with at least a 4%decrease in oxygen saturation. The AHI isthe average number of episodes of apneaMonth – For the purposes of this guide,means 30 days, regardless of the number ofdays in a specific calendar month.9
Sleep Centersthe registered polysomnographictechnologist examination forpolysomnographic technologists.Noncovered service or charge – A serviceor charge not reimbursed by the agency.Obstructive sleep apnea" or "OSA Thissyndrome refers to the interruption ofbreathing during sleep, due to obstructivetissue in the upper airway that collapses intothe air passage with respirationRespiratory Effort Related Arousals(RERA) – These occur when there is asequence of breaths that lasts at least tenseconds, characterized by increasingrespiratory effort or flattening of the nasalpressure waveform, which lead to an arousalfrom sleep. However, they do not meet thecriteria of an apnea or hypopnea. The degreeto which RERAs are associated with thesame sequelae as apneas and hypopneas isunknown, although clients with only RERAscan be symptomatic in terms of excessivedaytime sleepiness.Polysomnogram - The test results from apolysomnography"Polysomnography" - A multiparametrictest that electronically transmits and recordsspecific physical activities while a personsleeps. The recordings become data that areanalyzed by a qualified sleep specialist todetermine whether or not a person has asleep disorder.Revised code of Washington (RCW) –Washington State laws.Professional component – The part of aprocedure or service that relies on theprovider’s professional skill or training, orthe part of that reimbursement thatrecognizes the provider’s cognitive skill.RUL – Also called Reasonable UsefulLifetime.Technical component – The part of aprocedure or service that relates to theequipment set-up and technician’s time, orthe part of the procedure and servicereimbursement that recognizes theequipment cost and technician timeRegistered polysomnographictechnologist" or "RPSGT" - A sleeptechnologist credentialed by the board ofregistered polysomnographic technologiststo assist sleep specialists in the clinicalassessment, physiological monitoring andtesting, diagnosis, management, andprevention of sleep-related disorders withthe use of various diagnostic and therapeutictools. These tools include, but are notlimited to, polysomnograph, positive airwaypressure devices, oximeter, capnograph,actigraph, nocturnal oxygen, screeningdevices, and questionnaires. To becomecertified as a registered polysomnographictechnologist, a sleep technologist must havethe necessary clinical experience, hold CPRcertification or its equivalent, adhere to theboard of registered polysomnographictechnologists standards of conduct, and pass10
Sleep CentersAbout the Program(WAC 182-531-1500)What is the purpose of the Sleep Centers andMedicine program?The purpose of the Sleep Centers and Medicine program is to provide medically necessarydiagnostics, equipment, services, and supplies to eligible agency clients who are not enrolled in amanaged care plan and reside in: A homeA community residential settingA skilled nursing facilityWhen does the agency pay for sleep center andsleep medicine related care?The agency pays when it is: Prescribed by the client’s physician. Medically necessary, as defined under WAC 182-500-0070. Performed by an agency-designated center of excellence (COE) that is an independentdiagnostic testing facility, sleep laboratory, or outpatient hospital. Billed according to this billing guide. Provided and used within accepted medical care community standards of practice.The agency pays when the results are used to: Establish a diagnosis of narcolepsy or sleep apnea; or Evaluate a client's response to therapy, such as continuous positive airway pressure(CPAP)11
Sleep CentersBecoming an agency-approved Center ofExcellence (COE)To become an agency-approved COE, a sleep center must send the following documentation tothe Health Care Authority, Provider Enrollment, P.O. Box 45510, Olympia, WA 98504-5510: A completed Core Provider Agreement A copy of the sleep center's current accreditation certificate by the American Academy ofSleep Medicine (AASM)Note: Sleep centers must request reaccreditation from AASM in time to avoidexpiration of COE status with the agency.At least one physician on staff at the sleep center must be board certified in sleep medicine. If theonly physician on staff who is board certified in sleep medicine resigns, the sleep center mustensure another physician on staff at the sleep center obtains board certification or another boardcertified physician is hired. The sleep center must then send Provider Enrollment a copy of thephysician's board certification.If a certified medical director leaves a COE, the COE status does not transfer with the medicaldirector to another sleep center.The COE must maintain a record of the physician's order for the sleep study.12
Sleep CentersClient Eligibility(WAC 182-540-110(1))Most Apple Health clients are enrolled in an agency-contracted managed care organization(MCO). This means that Apple Health pays a monthly premium to an MCO for providingpreventative, primary, specialty, and other health services to Apple Health clients. Clients inmanaged care must see only providers who are in their MCO’s provider network, unless priorauthorized or to treat urgent or emergent care. See the agency’s Apple Health managed care pagefor further details.It is important to always check a client’s eligibility prior toproviding any services because it affects who will pay for the services.How do I verify a client’s eligibility?Check the client’s Services Card or follow the two-step process below to verify that a client hasApple Health coverage for the date of service and that the client’s benefit package covers theapplicable service. This helps prevent delivering a service the agency will not pay for.Is the client enrolled in an agency-contracted managed care organization (MCO), in a behavioralhealth organization (BHO), or is the client receiving services through fee-for-service (FFS)Apple Health?Verifying eligibility is a two-step process:Step 1. Verify the patient’s eligibility for Apple Health. For detailed instructions onverifying a patient’s eligibility for Apple Health, see the Client Eligibility, BenefitPackages, and Coverage Limits section in the agency’s ProviderOne Billing andResource Guide.If the patient is eligible for Apple Health, proceed to Step 2. If the patient is noteligible, see the note box below.Step 2. Verify service coverage under the Apple Health client’s benefit package. Todetermine if the requested service is a covered benefit under the Apple Health client’sbenefit package, see the agency’s Program Benefit Packages and Scope of Serviceswebpage.13
Sleep CentersNote: Patients who are not Apple Health clients may submit an application forhealth care coverage in one of the following ways:1.By visiting the Washington Healthplanfinder’s website at:www.wahealthplanfinder.org2.By calling the Customer Support Center toll-free at: 855-WAFINDER(855-923-4633) or 855-627-9604 (TTY)3.By mailing the application to:Washington HealthplanfinderPO Box 946Olympia, WA 98507In-person application assistance is also available. To get information about inperson application assistance available in their area, people may visitwww.wahealthplanfinder.org or call the Customer Support Center.Are clients enrolled in an agency-contractedmanaged care organization (MCO) eligible?(WAC 182-531-1500)Yes. Most Medicaid-eligible clients are enrolled in one of the agency’s contracted managed careorganizations (MCOs). For these clients, managed care enrollment will be displayed on the clientbenefit inquiry screen in ProviderOne.All medical services covered under an agency-contracted MCO must be obtained by the clientthrough designated facilities or providers. The MCO is responsible for: Payment of covered services Payment of services referred by a provider participating with the plan to an outsideproviderNote: A client’s enrollment can change monthly. Providers who are notcontracted with the MCO must receive approval from both the MCO and theclient’s primary care provider (PCP) prior to serving a managed care client.Send claims to the client’s MCO for payment. Call the client’s MCO to discuss payment priorto providing the service. Providers may bill clients only in very limited situations as described inWAC 182-502-0160.14
Sleep CentersNote: To prevent billing denials, check the client’s eligibility prior to schedulingservices and at the time of the service, and make sure proper authorization orreferral is obtained from the agency-contracted MCO, if appropriate. See theagency’s ProviderOne Billing and Resource Guide for instructions on how to verifya client’s eligibility.Managed care enrollmentApple Health (Medicaid) places clients into an agency-contracted MCO the same month they aredetermined eligible for managed care as a new or renewing client. This eliminates a person beingplaced temporarily in FFS while they are waiting to be enrolled in an MCO or reconnected witha prior MCO. This enrollment policy also applies to clients in FFS who have a change in theprogram they are eligible for.New clients are those initially applying for benefits or those with changes in their existingeligibility program that consequently make them eligible for Apple Health managed care.Renewing clients are those who have been enrolled with an MCO but have had a break inenrollment and have subsequently renewed their eligibility.Checking eligibility Providers must check eligibility and know when a client is enrolled and with whichMCO. For help with enrolling, clients can refer to the Washington Healthplanfinder’s GetHelp Enrolling page. MCOs have retroactive authorization and notification policies in place. The providermust know the MCO’s requirements and be compliant with the MCO’s policies.Behavioral Health Organization (BHO)The Health Care Authority manages the contracts for behavioral health services (mental healthand substance use disorder) for the following four Regional Service Areas (RSAs): Great Rivers: Includes Cowlitz, Grays Harbor, Lewis, Pacific, and Wahkiakum countiesNorth Sound: Includes Island, San Juan, Skagit, Snohomish, and Whatcom countiesSalish: Includes Clallam, Jefferson, and Kitsap countiesThurston-Mason: Includes Thurston and Mason countiesTo view a map and table of the integrated managed care plans available within each region,please see Changes coming to Washington Apple Health. You may also refer to the agency’sApple Health managed care webpage.See the agency’s Mental Health Services Billing Guide for details.15
Sleep CentersApple Health – Changes for January 1, 2019Effective January 1, 2019, agency-contracted managed care organizations (MCOs) in certainRegion Service Areas (RSAs) will expand their coverage of behavioral health services (mentalhealth and substance use disorder treatment), along with continuing to cover physical healthservices. The RSAs are outlined in the Integrated Managed Care Regions section.Apple Health clients who are not enrolled in an agency-contracted MCO for their physical healthservices (e.g., dual-eligible Medicare-Medicaid c
regarding the Sleep Centers and Sleep Medicine Program? Do one of the following: Contact the ; Billers and Providers "contact us" webpage Contact the Sleep Centers and Sleep Medicine program manager at: Division of Health Care Services/CQCT Health Care Authority P.O Box 45506 Olympia, WA 98504-5506 Who do I contact if I have a
