eviCore healthcare (eviCore) is Tufts Health Plan's sleep benefit manager for sleep studies, sleep therapy and resupply requests:
- Individual prior authorizations are required for Commercial, Tufts Health Direct and Tufts Health Together – MassHealth MCO and Accountable Care Partnership Plans (ACPP) members aged 18 years and older by eviCore.
- Notification is required through eviCore for Tufts Medicare Preferred HMO and Tufts Medicare Preferred Access (PPO) members.
While you may not be the provider responsible for obtaining prior authorization or notification, as a condition of payment, you must confirm that prior authorization has been obtained for Commercial, Tufts Health Direct and Tufts Health Together MCO and ACPP members or notification for Tufts Medicare Preferred HMO and Tufts Medicare Preferred Access (PPO) members prior to the member receiving services, equipment and/or supplies. Refer to the Prior Authorization/Notification Code List for a list of procedures, services, and items that require prior authorization or notification. Register and log in to the secure eviCore website at evicore.com or call 888.511.0401 to obtain and verify prior authorizations and submit and verify notifications.
Note: The eviCore sleep program does not apply to members of Tufts Health Plan Senior Care Options, Tufts Medicare Complement, Tufts Medicare Preferred Supplement, Commercial PPO plans with the PHCS network, Uniformed Services Family Health Plan (USFHP), Tufts Health Unify or Tufts Health RITogether.
For additional information for all products, refer to the Sleep Studies Payment Policy.
Sleep Studies
The ordering provider must request prior authorization/notification, as applicable, for all sleep studies, including but not limited to, the following:
- Polysomnogram
- Titration study
- Home sleep test
- Multiple sleep latency testing (MSLT) and maintenance of wakefulness studies
Rendering providers must be AASM-accredited for both facility-based and home-based testing and tests must be read by a board-certified sleep specialist. Refer to the Tufts Health Plan Sleep Management Program Overview for additional information.
- Using evidence-based criteria and guidelines, eviCore will review coverage requests and provide authorization or notification confirmation by fax for either a home-based or facility-based study, as appropriate. Authorizations and notifications for a home sleep test are valid for 120 days. Authorizations and notifications for a facility-based sleep test are valid for 90 days. DME authorizations are valid for 180 days.
- If prior authorization is requested but denied by eviCore, a letter will be sent to the member and provider with appeal rights. Providers may call eviCore for reconsideration at 888.511.0401.
- The guidelines used in such cases can be found on the eviCore website at evicore.com.
PAP Equipment and Supplies
Prior authorization/notification is required from eviCore for PAP equipment and supplies, as applicable.
All patients receiving PAP therapy equipment will be enrolled in the eviCore PAP Compliance Program. This is designed to ensure that patients prescribed PAP therapy use their equipment to effectively manage their diagnosed sleep disorder. Providers who are registered with eviCore can confirm a PAP therapy setup and monitor ongoing patient compliance through the site.
The initial patient orientation visit must be conducted by a respiratory therapist or LPN in either the member’s home or an agreed upon location which provides the member and provider a safe and HIPAA-appropriate location. Tufts Health Plan recommends that durable medical equipment (DME) providers use this as an opportunity to educate members on the manufacturer’s recommended maintenance/service requirements for PAP therapy equipment. DME providers may initiate requests for repairs or maintenance and service.
DME providers must contact members and confirm compliance via objective reporting from the device prior to the end of the third month of use. Compliance is defined as utilization of the prescribed therapy by the patient for an average of four hours a night for 70% of nights during the time of use (defined as the period of time that the member has the therapy equipment).
An objective machine generated report must be obtained by or provided to eviCore in each of the first 30, 60, and 90 day periods of use in order to extend authorization of services. If a member is noncompliant, it is the DME provider’s responsibility to notify the member’s provider. The DME provider must request authorization from the member’s provider to remove the PAP equipment from the member’s home when determined to be noncompliant or an Against Medical Advice (AMA) form must be signed by the member.