EviCore

For members of Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Plan Together, Tufts Health Medicare Preferred, Point32Health utilizes Evicore for sleep benefit management. (A utilization management program for sleep benefits is also in place for Havard Pilgrim Health Care, but that is administered by Evolent.)

EviCore performs utilization management for diagnostic studies, sleep apnea related devices and DME supplies and resupplies. Additionally, eviCore monitors PAP device generated patient compliance data.

Prior authorization requirements

  • 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.
  • 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, and multiple sleep latency testing (MSLT) and maintenance of wakefulness studies.
  • Prior authorization/notification is required from eviCore for PAP equipment and supplies, as applicable.

Refer to the Prior Authorization/Notification Code List for a list of procedures, services, and items that require prior authorization or notification.  For additional information, please refer to the Tufts Health Plan Sleep Management Program document and the Sleep Studies Payment Policy.

Requesting authorization from eviCore

Register and log in to the secure eviCore website at evicore.com or call 888-511-0401 to request prior authorization. Applicable guidelines are available on the eviCore website.

For rendering providers

Prior to providing sleep-related services, equiment, and/or supplies, please ensure that prior authorization has been optained for these members. 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.

PAP equipment and supplies

All patients receiving PAP therapy equipment will be enrolled in the eviCore PAP Compliance Program, which is designed to ensure that patients use their PAP equipment to effectively. The initial patient orientation visit must be conducted by a respiratory therapist or LPN, and members should be educated on the manufacturer’s recommended maintenance/service requirements for the equipment. DME providers must provide an objective machine generated report 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.