Professional Payment Policy
The following payment policy applies to Tufts Health Plan commercial contracted ancillary providers and
physicians who render professional services in an outpatient or office setting.
This policy applies to commercial 1 products. For information on Tufts Health Plan Medicare Preferred’s
policies and procedures, click here.
Note: Audit and disclaimer information is located at the end of this document.
Tufts Health Plan covers medically necessary sleep studies, diagnostic sleep testing, and medically
necessary sleep therapy and supplies, as described below.
Sleep studies are diagnostic studies performed to determine if a person has sleep apnea or other sleep
General Benefit Information 2
Services and subsequent payment are based on the member's benefit plan document. Providers and
their office staff are required to use self-service channels to verify effective dates and copayments for
commercial members prior to initiating services.
Reference the Electronic Services section of our website for our self-service channel options. Benefit
specifics should be verified prior to initiating services by logging on to our website or by contacting
Copayments, deductible and/or coinsurance may apply pursuant to the member’s benefit plan document.
Tufts Health Plan recommends not billing the member for the coinsurance and/or deductible amount until
the claim has processed so that the appropriate member responsibility can be determined. Both the
provider’s Statement of Account (SOA) and the Electronic Remittance Advice (ERA) will reflect the
member’s responsibility amount.
Reference the Authorization Policy for specific referral and authorization requirements.
Effective January 1, 2011, the Tufts Health Plan Precertification Department will no longer accept
requests for the prior authorization of sleep studies and related services. Facility-based sleep study tests,
home sleep study tests, CPAP/BiPAP, and sleep therapy resupplies require prior authorization by utilizing
the secure web portal of CareCore National, our sleep benefits manager. It is the responsibility of the
ordering provider to request and obtain prior authorization. The rendering (a.k.a interpreting) provider
should confirm that the authorization has been obtained. If authorization was not obtained or approved,
the claim will be denied. If prior authorization is requested but denied by CareCore National, a letter will
be sent to the member and provider with appeal rights.
Note: All sleep diagnostics, CPAP/BiPAP therapy, and resupplies require individual prior authorizations.
Commercial products include HMO, POS, PPO & CareLink when Tufts Health Plan is Primary Administrator
Eligibility is subject to retroactive reporting of disenrollment.
Originated 01/2004, Revised 11/2010 1 of 5 Tufts Health Plan – Sleep Studies Professional Payment Policy
Refer to the Medical Necessity Guidelines for CPAP/BiPAP, Multiple Sleep Latency Test and the
Polysomnogram Sleep Study Test for additional information.
Diagnostic Sleep Studies
Sleep studies conducted in the home require prior authorization by CareCore National. Ordering
providers should submit documentation of medical necessity for services requiring prior authorization
through CareCore National’s secure web portal. Documentation should detail:
The member’s suspected diagnosis and demographic information
Documentation of symptoms and complaints requiring the need for a diagnostic study, including
patient BMI, Epworth Sleepiness Scale Score and any co-morbidities.
Planned treatment, including medical rationale for the service requested
All pertinent medical information available for review
All sleep procedures require prior authorization with CareCore National.. Reference the Clinical
Resources section of our website for a list of procedures, services and items that require prior
authorization. Reference the CareLinkSM Prior Authorization List for a list of procedures, services and
items requiring prior authorization for CareLink members.
CPAP and BiPAP
The initial visit must be conducted by a Respiratory Therapist or LPN in either the patient’s home or an
agreed upon location which provides the member and provider a safe and HIPAA appropriate location for
the initial patient orientation. 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 CPAP or BiPAP equipment. DME providers or Tufts Health Plan
members 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 CareCore National in each of the first 30, 60, and 90 day periods of use in
order to extend authorization of services. If a member is non-compliant, it is the DME provider’s
responsibility to notify the member’s physician. The DME provider must request authorization from the
member’s physician to remove the CPAP or BiPAP equipment from the member’s home when
determined to be non-compliant or an Against Medical Advice (AMA) form must be signed by the patient
All sleep procedures and related equipment require prior authorization with CareCore National.
Reference the Clinical Resources section of our website for a list of procedures, services and items that
require prior authorization. Reference the CareLinkSM Prior Authorization List for a list of procedures,
services and items requiring prior authorization for CareLink members.
For a complete description of Tufts Health Plan’s commercial authorization requirements, reference the
Authorization section within the Tufts Health Plan Commercial Provider Manual.
Submit the most updated industry-standard codes.
Submit a modifier, when appropriate, with the corresponding CPT and/or HCPCS procedure code.
Submit the modifier that impacts reimbursement in the first modifier field and the informational
modifiers in the secondary fields.
Submit the appropriate ICD-9 diagnosis code(s) completed to the highest level of specificity.
Ancillary providers may bill only procedure code(s) in accordance with their Provider Agreement.
Originated 01/2004, Revised 11/2010 2 of 5 Tufts Health Plan – Sleep Studies Professional Payment Policy
Note: Annually and quarterly, HIPAA medical code sets 3 undergo revision by CMS, AMA and CCI.
Revisions typically include adding, deleting or redefining the description or nomenclature of new HCPCS,
CPT procedure and ICD-9 diagnosis codes. As these revisions are made public, Tufts Health Plan will
update its system to reflect these changes.
EDI Claim Submitter Information
Submit claims in HIPAA compliant 837P format for professional services. Claims billed with non-
standard codes will reject if billed electronically.
Paper Claim Submitter Information
Submit claims on a CMS-1500 form for professional services. Claim line(s) billed with non-standard
codes will deny.
Sleep Testing CPT Procedure Codes
The following table lists sleep testing CPT procedure codes that are accepted by Tufts Health Plan. The
absence or presence of a CPT procedure code is not an indication and/or guarantee of coverage and/or
95805* Multiple sleep latency testing
95806* Sleep study, unattended by a technologist
95807* Sleep study, attended by a technologist
95808* Polysomnography, 1-3 additional parameters, attended by a technologist
95810* Polysomnography, 4 or more additional parameters, attended by a technologist
95811* Polysomnography, 4 or more additional parameters, with CPAP initiation
G0398* Home sleep test/type 2 Porta
G0399* Home sleep test/type 3 Porta
G0400* Home sleep test/type 4 Porta
Note: (*) Asterisk denotes prior authorization is required.
Respiratory Equipment and Related Supplies
The following table lists respiratory equipment and related supplies HCPCS procedure codes that are
accepted by Tufts Health Plan. The absence or presence of a HCPCS procedure code is not an
indication and/or guarantee of coverage and/or reimbursement. Resupplies follow CMS guidelines when
compliance criteria are met.
A4615 Cannula, nasal
A7027 Combination oral/nasal mask, used with continuous positive airway pressure device,
A7030 Full face mask used with CPAP, each
A7031 Full face mask interface or replacement, each
A7032 Replacement for nasal application device, each
A7033 Replacement pillows for nasal application device, pair
A7034 CPAP Mask
A7035 Headgear used with CPAP
A7036 Chin strap used with CPAP
A7037 CPAP Tubing
A7038 Disposable filter for CPAP
A7039 Non-disposable filter for CPAP
HIPAA medical code sets include HCPCS, CPT Procedure and ICD-9 diagnosis codes.
Originated 01/2004, Revised 11/2010 3 of 5 Tufts Health Plan – Sleep Studies Professional Payment Policy
E0470* Respiratory assist device, Bi-level pressure, without backup rate feature, used with
E0471* Respiratory assist device, Bi-level pressure capability, with backup rate feature, used
with non-inv. interface
E0472* Respiratory assist device, bi-level pressure capability, with backup rate feature, used
with invasive interface, e.g., tracheostomy tube (intermittent assist device with
continuous positive airway pressure device)
E0561 Humidifier, non-heated, used with CPAP
E0562 Humidifier, heated, used with CPAP
E0601* Continuous airway pressure (CPAP) device
Note: (*) Asterisk denotes prior authorization is required.
Providers are reimbursed according to the Tufts Health Plan network contracted rates regardless of
where the service is rendered. Claims are subject to payment edits that are updated at regular intervals
and generally based on Centers for Medicare & Medicaid Services (CMS), specialty society guidelines,
drug manufacturers’ package label inserts and National Correct Coding Initiative (CCI).
Statement of Account (SOA)
The SOA is sent to all providers to provide information on the status of the claim(s) submitted to Tufts
Health Plan. The SOA indicates status of claims payments, denials and pending claims.
If the procedure code(s) submitted is not used in processing, the SOA will reflect the actual procedure
code(s) utilized by Tufts Health Plan to process the claim.
Electronic Remittance Advice (ERA)
The HIPAA compliant 835 ERA is an EDI transaction that providers may request to electronically post
paid and denied claims information to their accounts receivable system.
When an industry standard code(s) is submitted and accepted by Tufts Health Plan, the electronic
remittance advice will reflect the code(s) submitted and the actual procedure code(s) utilized by Tufts
Health Plan for claims processing.
October 2007: Added procedure codes and clarified that policy applies to ancillary providers and
March 2008: Clarified that the rendering (a.k.a. interpreting) provider should confirm that the
authorization has been obtained for sleep studies.
February 2009: Added three HCPCS codes to the policy; G0398, G0399 & G0400.
October 2010: Added the following information: Effective January 1, 2011, the Tufts Health Plan
Precertification Department will no longer accept requests for the prior authorization of sleep studies and
related services. Facility based sleep study tests, home sleep study tests, CPAP/BiPAP, and sleep
therapy resupplies require prior authorization by utilizing the secure web portal of CareCore National, our
sleep benefits manager.
November 2010: Added CPT code A7027 to the policy.
Originated 01/2004, Revised 11/2010 4 of 5 Tufts Health Plan – Sleep Studies Professional Payment Policy
Audit and Disclaimer Information
Tufts Health Plan reserves the right to conduct audits on any provider and/or facility to ensure compliance
with the guidelines stated in this payment policy. If such an audit determines that your office/facility did
not comply with this payment policy, Tufts Health Plan will expect your office/facility to refund all
payments related to non-compliance.
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every
claim is unique, the use of this policy is neither a guarantee of payment nor a final prediction of how
specific claim(s) will be adjudicated. Claims payment is subject to member eligibility and benefits on the
date of service, coordination of benefits, referral/authorization and utilization management guidelines
when applicable, and adherence to plan policies and procedures and claims editing logic.
This policy does not apply to CareLinkSM, or Private Health Care Systems (PHCS) network also known as
Multiplan members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s
provider arrangement for the purpose of CareLinkSM members.
Originated 01/2004, Revised 11/2010 5 of 5 Tufts Health Plan – Sleep Studies Professional Payment Policy