Don’t Request Sleep Study Prior Authorization without these Documents

As an outsourced Revenue Cycle Management (RCM) company serving US healthcare providers for nearly two decades, interactions with numerous physicians and decision-makers at sleep institutes have helped identify an area where many HCPs encounter hurdles – the sleep study prior authorization process.

Thus, to address this area of confusion among sleep centers and new prior authorization specialists, let’s discuss the vital documents without which a polysomnography prior auth request should not be submitted, no matter what!

Let’s go!

Embarking on the sleep study prior authorization journey: Clinical documentation

Sleep study prior authorization starts with providing comprehensive clinical notes that justify the need for a sleep assessment. These notes should offer an all-encompassing view of the patient’s health condition, including symptoms that impact sleep patterns.

Essential clinical paperwork includes:

• Medical history, featuring health issues, treatments, and any hereditary medical conditions that could affect sleep
• Physical examination report which provides an objective snapshot of the patient’s health
• Reports detailing the patient’s sleep disorder symptoms, which paint a clearer picture of the patient’s condition
• Documents concerning past treatments for the ailment in question are an equally important component of clinical documentation for pre-authorizations

Formalizing the request: The sleep study prior authorization form

A pivotal document that adds structure to the sleep study prior auth request is the Prior Authorization Form. This document must contain all necessary details about the patient and the requested service, paving the way for smooth processing.

Vital sections of the prior authorization form include:

• The patient information section, containing data such as name, D.O.B, insurance policy number, and contact details
• The provider’s information, mentioning provider’s name, contact details, and National Provider Identifier (NPI)
• The requested study’s description, the third most important section of the polysomnography PA form that specifies the type of study, the motivation for the study, and the intended date of the study

Supporting the case: Additional sleep study prior authorization documents

To fortify sleep study pre authorization requests, additional supporting documents are essential.

Additional supporting documents may include:

• Lab results or records that corroborate the need for a polysomnography
• Specialist reports, in case the patient has presented to a specialist like a pulmonologist, their reports can provide context to support the need for polysomnography pre-authorization requests
• Sleep diaries, if maintained by patients, to offer context and evidence of the patient’s sleep problems

Completing polysomnography prior-authorization requests: Provider’s details

Once the above documents and other case-specific paperwork are in place, it’s time to complete the PA request by including the sleep center/institute’s credentials.

Provider-specific details to be included are:

• National Provider Identifier (NPI), a unique identifier required to initiate any communication with payers
• Contact details, crucial for any engagement with insurance companies
• The Tax ID number, another identifier of paramount importance for the provider

Prior authorization services for sleep tests – Final thoughts

By understanding and meticulously following these steps, providers can expedite the prior-authorization process, ensuring timely treatment for patients.

Sleep centers that find these processes overwhelming, may consider outsourcing prior authorization services for sleep tests.

For unbiased consultation on how to ease the burden of pre-authorization requirements for sleep study centers or to know more about our industry best cost per FTE (prior auth specialists), please feel free to fill out the form below and we will get back to you as soon as possible.