One of the most frequently asked questions I receive daily pertains to Medicare, the “dreaded” insurance company.
There are specific rules, guidelines and standards that need to be adhered to in order to submit claims to Medicare. Actually, it’s a great idea to apply these same standards to all insurance companies with the exception of a couple. What are these guidelines and standards? I’m glad you asked.
1. The patient has a face-to-face clinical evaluation with the treating physician prior to the sleep test being ordered. (Not necessary for commercial insurance companies).
2. The patients AHI is equal to or greater than 5 and less than 14 with documentation of any of these comorbidities: EDS (excessive daytime sleepiness), impaired cognition, mood disorders, insomnia, hypertension (high blood pressure), ischemic heart disease or history of stroke.
3. The patients AHI or RDI is greater than 30 and the patient is not able to tolerate PAP or the treating physician determines that use of PAP is contraindicated.
4. The device is ordered by the treating physician following review of the sleep test. (Need to obtain an LOMN/RX from an MD for commercial insurance companies).
5. The device is provided and billed for by a licensed dentist.
It is also imperative that you obtain an ABN (Advanced Beneficiary Notice of Noncoverage). There are specific Medicare approved devices that must be used in order to be in compliance with Medicare.
There are additional forms that you need to have on hand in your office as well. Your 3rd party billing service can assist you in obtaining those forms.
Please do not hesitate to let me or your billing service know if you have any additional questions.