Prior Authorization
Regence (Carelon-managed) Prior Authorization for CPT 95810
Laboratory-assisted sleep studies including polysomnography for sleep apnea diagnosis · OR · commercial plans
Source
Regence commercial pre-authorization list - Carelon Sleep Medicine - ORNot medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.
Clinical criteria
Regence public commercial pre-authorization page lists 95810 under Carelon sleep medicine as requiring pre-authorization. This lane is limited to Regence commercial Carelon public program context for ID, OR, and UT; confirm the member's benefits, plan participation in the Carelon program through Availity, and current Regence/Carelon submission requirements. It does not answer FEP, Medicare Advantage, Medicaid, UMP, BlueCard/out-of-area, Premera, pharmacy, inpatient, emergent, or payment/coverage approval status.
Documentation checklist
- ✓Member eligibility and benefit verification
- ✓Availity confirmation that the member's plan participates in the Carelon program
- ✓Current Regence/Carelon authorization submission requirements
- ✓Clinical records supporting the requested service when requested by Regence or Carelon
Submission channels
Phone
1-877-291-0509How to submit the PA
- 1Verify the requirement against the current clinical policy PDF linked above.
- 2Gather documentation: Member eligibility and benefit verification, Availity confirmation that the member's plan participates in the Carelon program, Current Regence/Carelon authorization submission requirements….
- 3Submit via phone, or the payer portal.
- 4Document the reference number and follow up within 5 business days if no determination is received.
FAQ
- Does Regence (Carelon-managed) require prior authorization for CPT 95810?
- Yes. Regence (Carelon-managed) requires prior authorization for CPT 95810 (Laboratory-assisted sleep studies including polysomnography for sleep apnea diagnosis) under commercial plans in OR per its published clinical policy.
- What documentation does Regence (Carelon-managed) require for CPT 95810?
- Member eligibility and benefit verification; Availity confirmation that the member's plan participates in the Carelon program; Current Regence/Carelon authorization submission requirements; Clinical records supporting the requested service when requested by Regence or Carelon
- How long does Regence (Carelon-managed) take to respond to a PA request?
- Standard Regence (Carelon-managed) commercial PA determinations are returned within 5–14 business days for non-urgent requests and 72 hours for urgent (expedited) requests, per state-regulated and contractual timelines.
- What if Regence (Carelon-managed) denies the PA for CPT 95810?
- Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.
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