Why does Maine need its own guide?

Because MaineCare’s documentation standards are stricter than most commercial plans, and the three commercial plans each run different review cycles. A generic tool treats them the same and gets denied the same.

How is patient data handled?

The platform is built to HIPAA requirements. During early access, automation is tested with de-identified data, and no protected health information leaves your environment without a signed agreement.

Do we need an EHR integration?

No. The assistant works alongside any EHR from day one. Enter or paste the clinical findings and the forms, letter and tracking are generated from that. Integrations come later, when they are worth the IT project.

What does early access include?

A working account for your Maine program, a direct channel to the team, pricing locked at early-access rates for the life of the account and a say in what gets built next. No credit card and no commitment.

Maine sleep study prior authorization, without the MaineCare back-and-forth.

MaineCare, Anthem, Community Health Options and Harvard Pilgrim each want their own documentation. Prior Authorization Assistant fills the right form, drafts the letter and tracks the case for Maine sleep clinics.

See how it works

Built with US sleep programs. Payer guides for 8 states. HIPAA-ready.

Case 0142

Attended polysomnography

CPT: 95810
Plan: MaineCare

Intake
9:02
Payer requirements pulled for 95810
Letter
9:06
Medical necessity drafted, physician signed
Submitted
9:07
Form filled and checked, 0 fields missing
Approved
Day 2
Authorization number issued by the plan

Denial riskChecking

Built with sleep programs at

The cost of waiting

What a slow prior authorization costs in Maine

Prior authorization is the longest gap between an order and a study. For Maine sleep programs it is also where revenue quietly goes missing.

See how we fix it

Revenue Maine sleep programs leave uncollected each year

Average wait on a single authorization request

Forms a typical clinic processes a year

Claims delayed by missing or wrong documentation

Payer guides for 8 statesOpen the index

How it works

From order to approval, for every Maine plan

Maine programs are small teams facing MaineCare’s strict documentation rules and three commercial plans with different review cycles. The assistant does the paperwork so a two-person office can run like a large one.

Step 1.
Intake pulls the payer’s rules
Pick the study and the plan. The assistant lists exactly what that payer wants for that code, from the Epworth score to the sleep history, and flags what is still missing from the chart.
MaineCare requirements
95810
Epworth Sleepiness Scale documented
ESS 14, recorded 12 May
Symptoms present for at least three months
Snoring, witnessed apneas
BMI and neck circumference recorded
BMI 34, neck 17.5 in
Home sleep test failed or contraindicated
Add HST result or physician note
Order with diagnosis code
G47.33, signed
Checking the chart against the list.
Step 2.
The medical necessity letter drafts itself
Clinical findings become a letter written in the language reviewers approve: symptoms, duration, comorbidities, the study ordered and why. Your physician signs. Nobody retypes.
Letter of medical necessity
To MaineCare
Re: Attended polysomnography, CPT 95810. Diagnosis G47.33, obstructive sleep apnea.
The patient presents with excessive daytime sleepiness (Epworth 14), loud snoring and witnessed apneas reported by a bed partner, persisting for more than six months.
Examination shows a BMI of 34 and a neck circumference of 17.5 inches. The patient has hypertension that remains poorly controlled on two agents.
An attended polysomnography (CPT 95810) is medically necessary to confirm obstructive sleep apnea and to guide therapy. A home study is contraindicated given the cardiovascular comorbidity.
Electronically signed by the ordering physician. Ready for submission.
Step 3.
Forms are filled, not typed
Payer and state forms are completed from the same data in one pass. Every field is checked against the requirement list before anything leaves the clinic.
MaineCare authorization request
Form 7 of 7
Member ID
W281 440 912
Service requested
Attended polysomnography
CPT
95810
ICD-10
G47.33
Place of service
22, outpatient hospital
Rendering provider NPI
1538 221 907
Supporting documents
Letter, ESS, HST result
Checking every field against the list.
Submit

Every case on one board

Approved, pending, waiting on documents, denied. Each case shows its age and its next action, so nothing sits in a fax queue for three weeks unnoticed.

Open cases

5 of 23

Case	Study	Plan	Age	Status
0142A. W.	PSG 95810	Aetna	1 d	Approved
0141B. K.	HST 95806	Cigna	3 d	Pending review
0139C. R.	CPAP E0601	Medicaid	2 d	Needs HST result
0138D. M.	PSG 95811	UHC	6 h	Submitted
0135E. L.	BiPAP E0470	Humana	9 d	Denied, appeal drafted

Why it is hard

Same study. Four rulebooks.

One attended polysomnography, four Maine plans, four different lists before anyone says yes. The assistant keeps every list current and checks your chart against the one that matters.

Example requirements for CPT 95810 across four plans
Requirement for 95810	MaineCare	Anthem	Community Health Options	Harvard Pilgrim
Epworth Sleepiness Scale score	Required	Required	Sometimes	Required
Symptom history of three months or more	Required	Required	Required	Sometimes
BMI and neck circumference	Sometimes	Required	Not asked	Required
Home sleep test attempted or contraindicated	Required	Sometimes	Required	Required
Face-to-face visit within six months	Not asked	Required	Sometimes	Required
Signed order with diagnosis code	Required	Required	Required	Required

Required Required
Sometimes Sometimes, depending on history
Not asked Not asked

MaineCare

5 of 6

RequiredEpworth Sleepiness Scale score
RequiredSymptom history of three months or more
SometimesBMI and neck circumference
RequiredHome sleep test attempted or contraindicated
RequiredSigned order with diagnosis code

Anthem

6 of 6

RequiredEpworth Sleepiness Scale score
RequiredSymptom history of three months or more
RequiredBMI and neck circumference
SometimesHome sleep test attempted or contraindicated
RequiredFace-to-face visit within six months
RequiredSigned order with diagnosis code

Community Health Options

5 of 6

SometimesEpworth Sleepiness Scale score
RequiredSymptom history of three months or more
RequiredHome sleep test attempted or contraindicated
SometimesFace-to-face visit within six months
RequiredSigned order with diagnosis code

Harvard Pilgrim

6 of 6

RequiredEpworth Sleepiness Scale score
SometimesSymptom history of three months or more
RequiredBMI and neck circumference
RequiredHome sleep test attempted or contraindicated
RequiredFace-to-face visit within six months
RequiredSigned order with diagnosis code

Example requirement set for an attended polysomnography. The live rules for each plan are maintained in the product and change when the plan changes.

Plans we track

Maine plans with sleep study requirements on file

Prior authorization in Maine means a different form, threshold and turnaround for each of these plans. The assistant keeps every one of them current.

Medicaid

State program with its own documentation standard and review timeline.

MaineCare

Commercial

Employer and individual coverage with plan-specific medical policies for sleep testing.

Anthem
Community Health Options
Harvard Pilgrim

Requirements are maintained per plan for attended polysomnography, home sleep apnea testing, CPAP and BiPAP devices and supplies. If your program bills a Maine plan not listed here, tell us during early access.

Coverage

Built around sleep medicine, code by code

Requirements are maintained per study, per device and per plan, for MaineCare, Anthem, Community Health Options and Harvard Pilgrim. Not a generic tool with a sleep template bolted on.

Studies, devices and supplies covered, with billing codes
Code	Study, device or supply
In-lab study
95810	Attended polysomnography
95811	Polysomnography with CPAP or BiPAP titration
95805	Multiple sleep latency test
Home study
95806	Home sleep apnea test, unattended
95800	Home sleep apnea test with peripheral arterial tone
Durable medical equipment
E0601	CPAP device
E0470	BiPAP without backup rate
E0471	BiPAP with backup rate
Supplies
A7030 to A7039	Masks, cushions, tubing and filters

Early access

What Maine programs told us they need

We are building with a small group of US sleep centers. These are the problems they brought us, in their words.

“MaineCare documentation is exact. If the checklist told us what was missing before we sent it, we would stop losing two weeks per case.”
Maine Sleep Center
Family medicine
“We jump between the Community Health Options portal and Anthem’s all day. One board for every case is the whole ask.”
Maine Pulmonary & Sleep
Sleep disorder specialist
“A medical necessity letter drafted from the chart, in the language MaineCare reviewers approve, would save our physician an hour a day.”
Portland Sleep Center
DME specialist

Payer guides

Prior authorization rules, state by state

Medicaid programs and regional plans each ask for something different. We keep a requirements guide for every state we serve.

Questions

Questions Maine sleep programs ask about prior authorization

MaineCare, Anthem, Community Health Options and Harvard Pilgrim, with sleep study, PAP therapy and supply requirements maintained per plan.

Early access for Maine sleep centers

We are onboarding a small number of Maine programs while we build. If your clinic runs in-lab or home studies and fights MaineCare for every one, we would like to work with you.

No credit card. No commitment. A reply within two business days.

Early-access pricing locked for the life of your account
A direct line to the team shaping what gets built next
First in line as automation expands across sleep workflows