PRECERTIFICATION & REFERRALS

Precertification

Precertification, also known as prior authorization, is mandated by many insurance providers requiring designated procedures to be reviewed for medical necessity and approval prior to being provided.

Once we receive the oneForm, we submit for precertification to insurance. Either Neurocare or the payor will reach out to the referring physician if any additional information is required.

Please note that precertification processing time can vary by payor. For more information, please call us at 617-796-7766.

Referrals

Some insurances require that a Referral be obtained for services that are not considered primary care. Usually, the referral number must be obtained directly by the PCP’s office when a referral is made to another specialist and/or to another healthcare provider (such as a sleep center). Separate referral numbers are required for each referral.

If the consulting specialist orders a sleep study, some providers will still require that the PCP obtain the referral number for the sleep study. Masshealth, Tricare, Network Health, and some Blue Cross are examples of payors that may require referrals for some plans. If a payor requires a referral, we are unable to move forward with the scheduling process until the provider submits the referral. 

Once a referral is obtained, please fax to:
617-796-9099

 

HOW WILL I KNOW IF MY PATIENT IS APPROVED FOR A SLEEP STUDY?

Both the patient and the physician will be notified by the insurance company by fax/letter. Patients approved for in-lab studies will be contacted by Neurocare to schedule an appointment. If Neurocare is the assigned HST provider, the patient will be contacted to schedule. Neurocare will notify the referring physician if HST is assigned to another sleep testing provider.

IF MY PATIENT IS APPROVED FOR AN HST, WHO PROVIDES THE TESTING?

Neurocare Center for Sleep is accredited by the American Academy of Sleep Medicine for Home Sleep Apnea Testing and is contracted with most payors, including:
Harvard Pilgrim Health Care, Blue Cross Blue Shield, United Healthcare, Aetna, Medicare, Fallon, Cigna, Tufts, Neighborhood Health Plan, and Unicare/GIC

Some of our hospital sites provide HST testing and Neurocare will coordinate scheduling with the appropriate provider

WHAT ARE MY OPTIONS IF MY PATIENT IS DENIED BY THE INSURANCE PAYOR FOR A SLEEP STUDY?

If an in-lab study is denied and if the order did not permit Home Sleep Testing, then Neurocare will provide referring physicians with the information to appeal the outcome determination with the payor

Consider referring to a Sleep Specialist for consultation and management, including order of testing and justification of medical necessity/precertification

WHAT IF I ORDER A TITRATION STUDY AND THE PROVIDER APPROVES AN AUTO-PAP?

Please contact the durable medical equipment (DME) company listed on the authorization sent to your office in order to provide them with the authorization number and initiate the process to obtain APAP for your patient. Neurocare is not a DME provider and cannot facilitate the process further.

 
 
 
 

Neurocare, Center for Sleep

70 Wells Avenue, Newton MA 02459
ph. 617-796-7766
fax 617-796-9099

© 2018 Neurocare, Inc.  All rights reserved.

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