Why does North Carolina need its own guide?

Because the managed-care plans and the commercial plans do not accept the same forms, thresholds or turnaround expectations for the same study. The assistant knows which rules apply to which plan.

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 North Carolina 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.

North Carolina sleep study prior authorization, approved on the first submission.

NC Medicaid, Healthy Blue, Blue Cross NC, Aetna, Cigna and Ambetter each ask for something different. Prior Authorization Assistant fills the right form, drafts the letter and tracks the case for North Carolina sleep centers.

See how it works

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

Case 0142

Attended polysomnography

CPT: 95810
Plan: Blue Cross NC

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 North Carolina

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

See how we fix it

Revenue North Carolina 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 North Carolina plan

North Carolina’s move to Medicaid managed care added plans and rules on top of a busy commercial market. The assistant keeps each plan’s sleep requirements current and does the paperwork before anyone opens a portal.

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.
Blue Cross NC 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 Blue Cross NC
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.
Blue Cross NC 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 North Carolina 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	NC Medicaid	Healthy Blue	Blue Cross NC	Aetna
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

NC Medicaid

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

Healthy Blue

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

Blue Cross NC

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

Aetna

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

North Carolina plans with sleep study requirements on file

Prior authorization in North Carolina 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.

NC Medicaid

Medicaid managed care

Authorizations go to the plan, not the state. Each plan keeps its own form and list.

Healthy Blue

Commercial

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

Blue Cross NC
Aetna
Cigna

Marketplace

Exchange coverage that follows the carrier’s commercial sleep policy.

Ambetter

Requirements are maintained per plan for attended polysomnography, home sleep apnea testing, CPAP and BiPAP devices and supplies. If your program bills a North Carolina 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 NC Medicaid, Healthy Blue, Blue Cross NC, Aetna, Cigna and Ambetter. 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 North Carolina 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.

“NC Medicaid and Healthy Blue set the pace of our sleep pipeline. We want to know a case is clean before it goes, not three weeks later.”
North Carolina Sleep Center
Family medicine
“CPAP and BiPAP approvals are the wall we hit most. A requirement list per plan, checked before submission, is what we have been asking for.”
Triangle Sleep Specialists
Apnea specialist
“Ambetter, Cigna and Healthy Blue requirements in one place would save our clinic hours every week.”
Raleigh Sleep Associates
Sleep disorder 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 North Carolina sleep programs ask about prior authorization

NC Medicaid and Healthy Blue, plus Blue Cross NC, Aetna, Cigna and Ambetter, with sleep study, PAP therapy and supply requirements maintained per plan.

Early access for North Carolina sleep centers

We are onboarding a small number of North Carolina programs while we build. If your clinic runs in-lab or home studies and fights NC Medicaid 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