There are three ways you can submit your pre-determination or claim:

• Check if your provider is registered with PROVIDERnet. If so, they will be able to submit both your pre-determination request and claim on your behalf.
• Sign into your Member Profile account, digitally complete our Standard Health Claim form, and upload all the required documentation along with a detailed quote or paid in full receipt. If you haven’t set up your account, you can sign up in five minutes or less.
• Complete our Standard Health Claim form and attach all the required documentation, including a detailed quote or paid in full receipt, and mail to Pacific Blue Cross, PO Box 7000, Vancouver, BC, V6B 4E1.

According to clinical evidence, only Canadian adults with moderate or severe OSA as diagnosed by a sleep study require sleep apnea equipment intervention. For children, sleep apnea equipment intervention may be recommended by their primary care practitioner for mild sleep apnea.

The respiratory disturbance index (RDI) includes not only apneas and hypopneas but may also include other subtle breathing irregularities. The apnea-hypopnea index (AHI) measure is more commonly used by Canadian research centres to assess sleep apnea severity.

First sleep apnea device

• Sleep study report (past or present)
• Equipment quote/ invoice from the medical supplier
• Prescription from MD/NP

Replacement sleep apnea device
(without an approved sleep study on file with Pacific Blue Cross)

• Sleep study (past or present) OR 30-day compliance report
• Equipment quote/ invoice from the medical supplier
• Prescription from MD/NP

Replacement sleep apnea device
(with an approved sleep study on file with Pacific Blue Cross) 

• Equipment quote/ invoice from the medical supplier

If you are unable to locate your previous sleep study, we will accept a compliance report showing the most recent 30 days of usage. If the compliance report is submitted in lieu of the sleep study, you will be required to submit a current compliance report when your equipment needs replacing.

It is up to your medical team to choose the right equipment to manage your sleep apnea. 

If a member is switching equipment types (e.g., continuous positive airway pressure equipment to bi-level positive airway pressure equipment), we may request additional documentation to support the need for an equipment change or modification.

Approved pre-determinations will allow members and providers to submit claims for the applicable sleep equipment, according to their benefit limitations. If you have submitted an eligible sleep study, once eligibility has been confirmed under the plan, and coverage with Pacific Blue Cross remains in effect, you will not have to complete the pre-determination process again for the same sleep equipment in the future.

If you submit a compliance report in lieu of a sleep study, you will be required to submit a current compliance report when your equipment needs replacing, for our review.

Members must meet the pre-determination requirements for sleep equipment to receive coverage. If you haven’t met the requirements and your physician still feels that you need equipment, please submit an appeal for review. We will require a physician’s letter to explain the basis for appeal. Any fees associated with this appeal are not eligible under your policy.

Yes, all members must meet our pre-determination process for sleep equipment coverage eligibility.

If you are already signed up for Member Profile, you will receive a notification when your pre-determination or claim has been processed.   You will be able to sign in through our website and view your pre-determination and claim details.  If you haven’t set up your account, you can sign up in five minutes or less.

If a provider has submitted a pre-determination or claim on your behalf, you will not receive a notification. However you can sign into your Member Profile account and view the status of the pre-determination or claim.