Reminder of our CPAP & BiPAP rental guidelines
We’re sharing a quick reminder of our continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) device capped rental guidelines. We hope these guidelines will support you in managing both authorizations and billing for these rentals for our members.
CPAP and BiPAP device rental management
Three-month trial period – no authorization required
CPAP and BiPAP rentals for all members start with a three-month trial period. No prior authorization is required for this trial, during which the member must demonstrate that they meet continued use compliance. Compliance details are available in medical policy 91333 – Obstructive Sleep Apnea.
Post-trial period – authorization required
After the trial period, authorization for continued use is required, whether or not the member met the compliance criteria.
- Member met compliance: Submit an authorization request for the remainder of the rental cap period (seven additional months for commercial and Medicaid, and 10 additional months for Medicare) with evidence of compliance.
- Member didn’t meet compliance: Submit a retrial authorization request immediately. Retrial requests require a new face-to-face office visit with the member.
CPAP and BiPAP rental authorizations are managed in GuidingCare, accessed through prism’s authorization request form (login required).
Replacement devices – authorization required
If a replacement device is needed, submit a new authorization request with documentation of proper use and continued benefit for clinical re-evaluation.
CPAP and BiPAP device rental billing
As capped DME rentals, CPAP and BiPAP device rentals should be billed monthly, covering the entire period of the rental without skipping months. As noted above, the first three months (trial period) are waived from authorization requirements. See medical policy 91333 – Obstructive Sleep Apnea for billing codes.
More information
Find additional information on DME authorizations and billing.