What the pre-determination is for
The form asks Pacific Blue Cross whether a member’s extended health plan will cover a sleep apnea device before it is bought. Completing it doesn’t mean approval. Coverage depends on the member’s plan and Pacific Blue Cross’s own criteria.
It is sometimes confused with a sleep disorder referral, which is a separate request to a sleep clinic for the study itself.
Who completes it
The member completes Part 1 and signs Part 4, the consent and declaration. The prescribing physician completes Part 2. The device provider completes Part 3 and attaches the sleep study.
Most often the form passes through three hands: the patient fills in Part 1 and signs, brings it to you for Part 2, then takes it to the CPAP vendor for Part 3 before sending it in. In Medulla, you send Part 1 and Part 4 to the patient over a secure link before or after the visit. They complete them on the form itself, and their answers land on the same PDF you complete Part 2 on, so the patient leaves with one form that only needs the provider’s part.
How to fill in Part 2
Prescriber and diagnosis
Tick GP or specialist and give the specialist type if relevant, then your name. Enter the diagnosis and its severity as the sleep study reported it.
Co-morbidities
The form asks for co-morbidities or other conditions Pacific Blue Cross should know for its eligibility review. List the relevant ones from the chart, such as hypertension, obesity, heart failure or diabetes.
Device prescribed and history
Enter the type of device prescribed. Say whether it is the patient’s first sleep apnea device, and if not, what they used and for how long. When switching between devices, such as CPAP to a mandibular advancement device, give the medical reason.
Certification
Sign and date the statement that you are the primary physician managing the patient’s sleep apnea and consulted them in person, or explain if you didn’t.
Common reasons it’s sent back
- No sleep study report attached, or an AHI not shown on it.
- A device switch with no medical reason.
- Part 4 not signed by the member.
- No explanation when the physician didn’t see the patient in person.
- Stapled pages or receipts, which the form asks members to avoid.
Submitting and who pays
The member sends the form to Pacific Blue Cross by mail to PO Box 7000, Vancouver, by drop-off at 4250 Canada Way, Burnaby, or by fax. The patient pays any fee for the form, which the plan doesn’t reimburse.