Sleep Equipment and Supplies FAQs
Pacific Blue Cross is committed to ensuring that health plans remain affordable and sustainable for everyone’s benefit. We also recognize the importance of providing access to sleep apnea equipment for members who can benefit clinically from this technology.
Before submitting your first sleep equipment claim, Pacific Blue Cross recommends providers submit a pre-determination to assess eligibility. As part of the pre-determination process you will be required to provide:
- A detailed quote for required sleep equipment and/or supplies
- A prescription for sleep equipment OR diagnosis of obstructive sleep apnea (OSA) from a medical doctor or nurse practitioner (MD/NP).
- A sleep study showing an AHI score greater than or equal to 15. If unavailable, a 30-day compliance report can be submitted for equipment replacements only. If the AHI is between 5 and 15, a MD/NP letter explaining co-morbidities may be submitted for our review.
If we determine the sleep equipment meets eligibility criteria 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.
In addition to the above documents, First Nations Health Authority (FNHA) clients must also submit a 30-day trial compliance report for initial sleep equipment, or a 30-day compliance report for replacement equipment.
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What are the clinical guidelines for Obstructive Sleep Apnea?
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.
Sleep Apnea Severity Eligible Apnea Hypopnea Index (AHI) Score None/Minimal No Less than 5 AHIs per hour Mild No Greater than or equal to 5, but fewer than 15 AHIs/hour Moderate Yes Greater than or equal to 15, but fewer than 30 AHIs/hour Severe Yes Greater than or equal 30 AHIs/hour -
Who is an eligible sleep equipment and supplies provider?
Providers must be accredited by the College of Physicians and Surgeons of BC (CPSBC) Diagnostic Accreditation Program (DAP) to register for PROVIDERnet, our online portal that allows direct billing.
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Why are you not asking for the client's Respiratory Disturbance Index?
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 centers to assess sleep apnea severity.
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What information is needed to submit a pre-determination?
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
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Do I need to submit the Sleep Apnea Device Pre-Determination form?
Pacific Blue Cross recommends submitting a pre-determination to assess eligibility. Please make sure to submit the requested documentation when submitting the claim.
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What if this is the first sleep equipment I’m submitting for this client?
To ensure that we have the right medical documentation on file, Pacific Blue Cross recommends that providers submit a pre-determination with the required documentation to assess eligibility.
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What if I have previously submitted a sleep equipment claim for this client to Pacific Blue Cross?
If we do not have a copy of the sleep study on file, the next time the member is eligible for sleep equipment, you will be required to submit a pre-determination or claim with the required documentation to assess eligibility. We accept copies of sleep studies completed in the past, and members do not need to repeat a sleep study.
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What if I don’t have a copy of the client’s previous sleep study?
If there is no copy of the 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 the equipment needs to be replaced.
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Will Pacific Blue Cross choose which device the member can receive?
The member’s medical team is responsible for choosing the most appropriate equipment for managing the member’s 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.
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What happens when sleep equipment pre-determination is approved?
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 and your eligibility has been confirmed under the plan, you will not have to complete the pre-determination process again for the same sleep equipment, as long as your coverage with Pacific Blue Cross remains in effect.
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.
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What happens if the sleep equipment pre-determination is not approved?
Members must meet the pre-determination requirements for sleep equipment to receive coverage. If they have not met the requirements and their physician still feels that the equipment is needed, please submit an appeal for review. We will require a physician’s letter to explain the basis for the appeal. Any fees associated with this appeal are not eligible under the members’ policy.
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How do I submit a pre-determination or a claim?
Sign into your PROVIDERnet account to submit a pre-determination or a claim on behalf of the member. Make sure to upload all the required documentation.
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How will I know if the pre-determination or claim has been processed?
You will receive a notification on your PROVIDERnet account when the pre-determination or claim has been processed.