MEDICAL POLICY – 1.01.524
Positive Airway Pressure (PAP) Devices for the Treatment
of Obstructive Sleep Apnea
BCBSA Ref. Policy: 2.01.18
Effective Date
May 1, 2017
RELATED MEDICAL POLICIES:
Last Revised:
April 11, 2017
2.01.503
Replaces:
N/A
Polysomnography and Home Sleep Study for Diagnosis of Obstructive
Sleep Apnea
2.01.532
Intraoral Appliances for the Treatment of Obstructive Sleep Apnea
Select a hyperlink below to be directed to that section.
POLICY CRITERIA | CODING | RELATED INFORMATION
EVIDENCE REVIEW | REFERENCES | HISTORY
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Introduction
Obstructive sleep apnea is a breathing disorder during sleep where an individual does not
breathe regularly or deeply enough to keep adequate oxygen levels in the blood. Usually this
results from a blockage in the upper airway due to any of the following: throat muscles
collapsing, the tongue falling into the airway, or large tonsils or adenoids getting in the way of
airflow. For most people the best treatment for sleep apnea is a positive airway pressure (PAP)
devices that is used while sleeping. A PAP device works by increasing air pressure in the throat
to prevent it from collapsing as a person breathes. Using a PAP device includes wearing a fitted
mask. There are three main types of PAP devices.
CPAP: Continuous positive airway pressure device provides a stream of air at one steady
pressure during sleep. This is the most commonly used device and works for most people.
Modifications of basic PAP devices with various pressure relief technologies (A-Flex, Bi-Flex, CFlex and C-Flex +) are also available.
BiPAP: Bilevel positive airway pressure (also called BPAP) has two settings. One setting is for
when you breathe in and the other is for when you breathe out. BiPAP is often the second line
treatment, if C-PAP does not work
APAP: Automatic positive airway pressure has certain settings and the pressure will
automatically adjust itself as a person sleeps to ensure the airway stays open. This device is
often used to determine what pressures are needed to treat a person with sleep apnea, and can
be used in the home setting.
This policy describes when a PAP device may be considered medically necessary and how the
health plan pays for PAP devices.
Note:
The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The
rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for
providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can
be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a
service may be covered.
Policy Coverage Criteria
Device
Investigational
Other devices used for
The following devices are considered investigational to treat
obstructive sleep apnea
OSA:
(OSA) treatment

Nasal expiratory positive airway pressure (EPAP) device (e.g.,
Provent ®)

Oral pressure therapy (OPT) device (e.g., The Winx™ Sleep
Therapy System)

Adaptive servo-ventilation (ASV) device
Note:
Intra-Oral Devices – Intra-oral devices for treatment of obstructive sleep
apnea are addressed in a separate medical policy (see Related Policies).
Device
Medical Necessity
Continuous positive airway
A continuous positive airway pressure (CPAP) device may be
pressure (CPAP)
considered medically necessary for adult or pediatric patients
diagnosed with obstructive sleep apnea (OSA) when the
following criteria are met:
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Device
Medical Necessity

A physician with training in sleep disorders evaluated the
patient and ordered the CPAP device AND all of the following:
o
All CPAP devices require a 3 month rental period prior to
purchase
o
During the first three months adherence to therapy is
documented for at least 30 days
o
Adherence is defined as use of PAP device for 4 or more
hours per night on 70% of nights during the 30 day period
**Note:

A claim submitted with the KX modifier is considered
documentation of adherence (see Documentation and Coding
sections).

The Company requires a full 3 months rental before purchase,
even if the criteria are met within the first month.

A successful CPAP trial will allow purchase of a CPAP unit for up
to 12 months following that trial.
Auto-adjusting PAP
A bi-level positive airway pressure (BiPAP/BPAP) or auto-
(APAP)
adjusting PAP (APAP) device may be considered medically
OR
necessary for patients diagnosed with OSA when the following
Bi-level airway pressure
criteria are met:
(BiPAP/BPAP)

A three month trial of CPAP was ineffective in resolving OSA
symptoms
AND

A physician with training in sleep disorders evaluated the
patient and ordered the APAP or BiPAP device
PAP accessories and
Accessories and supplies may be considered medically
supplies
necessary when used with a PAP device eligible for coverage
benefits.
Accessory add-ons and upgrades of an existing PAP device are
considered not medically necessary when a current PAP device
is functional and meets the member’s current basic functional
medical needs.
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Rental/Purchase/Repair/
Coverage Eligibility
Replacement
Continued PAP Device
If a patient fails to meet the adherence criteria during the first

Rental
three-month trial rental period, a second three-month (12

Failed initial PAP device
weeks) rental for a CPAP trial, when requested, may be
trial
considered if documentation is submitted showing:

The patient was re-evaluated by the treating physician or
respiratory therapist and

Prior to purchase the patient adhered to using the PAP device
during the second three-month (12 weeks) trial rental period.
If a CPAP device was used for more than three months without
OSA symptom relief and the physician ordered a BiPAP device,
a clinical re-evaluation must be completed before benefits are
provided. There must be documentation of adherence to
therapy during the three-month (12 weeks) trial with the
BiPAP device (see Documentation section).
Repair
Repair of a patient-owned PAP device is eligible for coverage
when:

Repairs are needed to make the device functional due to
reasonable wear and tear or accidental damage due to a
specific incident

Replacement
The manufacturer’s warranty has expired
Replacement of a patient-owned device is eligible for coverage
when:

The five year reasonable useful lifetime (RUL) has passed
AND

The device is not working, and cannot be repaired
OR

During the five year RUL because of loss, theft, or irreparable
damage due to a specific incident
Notes:
Replacement does not require a new clinical evaluation, sleep test, or 3month rental period.
The RA modifier is submitted for replacement of member-owned PAP
equipment (see Coding section).
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Documentation
For re-evaluation, the patient’s medical record should include documentation of visits after
PAP therapy along with the following:

Statement about PAP use adherence and effectiveness of resolving OSA symptoms

Plans for ongoing treatment

The specific interventions provided to help the patient use the equipment effectively and
resolve any ongoing OSA symptoms

The reason(s) for a change from a CPAP to BiPAP device, if applicable
Medical records for re-evaluations should include detailed narrative notes about the face to face
clinical assessment. This information does not have to be submitted with the claim but must be
kept by the supplier and treating practitioner(s) and be available if requested.
For adherence, the patient’s medical record should include documentation of PAP device
therapy in the form of the following:

Copy of a usage report from the PAP device’s memory

A statement that the written report was reviewed by the treating physician, respiratory
therapist or supplier
Coding
CPT
94799
Unlisted pulmonary service or procedure
HCPCS
Positive Airway Pressure Device
E0470
Respiratory assist device, Bi-level pressure capability, without backup rate feature, used with noninvasive
interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
E0471
Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive
interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
E0601
Continuous airway pressure (CPAP) device
ICD-10 CM
G47.33
Obstructive sleep apnea (Adult) (Pediatric)
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Maximum Reasonable
Accessories
A4604
and Necessary
Tubing with integrated heating element for use with positive airway
1 per 3 months
pressure device
A7027
Combination oral/nasal mask, used with continuous positive airway
1 per 3 months
pressure device, each –
A7028
Oral cushion for combination oral/nasal mask, replacement only, each –
2 per 1 month
A7029
Nasal pillows for combination oral/nasal mask, replacement only, pair –
2 per 1 month
A7030
Full face mask used with positive airway pressure device, each –
1 per 3 months
A7031
Face mask interface, replacement for full face mask, each –
1 per 1 month
A7032
Cushion for use on nasal mask interface, replacement only, each –
2 per 1 month
A7033
Pillow for use on nasal cannula type interface, replacement only, pair
2 per 1 month
A7034
Nasal interface (mask or cannula type) used with positive airway
1 per 3 months
pressure device, with or without head strap
A7035
Headgear used with positive airway pressure device
1 per 6 months
A7036
Chinstrap used with positive airway pressure device
1 per 6 months
A7037
Tubing used with positive airway pressure device
1 per 3 months
A7038
Filter, disposable, used with positive airway pressure device
2 per 1 month
A7039
Filter, nondisposable, used with positive airway pressure device
1 per 6 months
A7044
Oral interface used with positive airway pressure device, each
A7045
Exhalation port with or without swivel used with accessories for positive
airway devices, replacement only
A7046
Water chamber for humidifier, used with positive airway pressure device,
1 per 6 months
replacement, each
Patient Compliant Monitoring Devices
A9279
Monitoring feature/device, stand-alone or integrated, any type, includes
Integral to PAP; not eligible for
all accessories, components and electronics, not otherwise classified
separate reimbursement.
Humidifier
E0561
Humidifier, nonheated, used with positive airway pressure device
Covered when used with allowed
E0470 or E0601*
E0562
Humidifier, heated, used with positive airway pressure device
Covered when used with allowed
E0470 or E0601*
Modifiers
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KX
On initial claims (first through third months) and continued coverage
Covered when used with allowed
(beyond first 3 months), suppliers must add a KX modifier to codes for
E0470 or E0601*
PAP equipment. **
NU
New Equipment
RA
Replacement of patient-owned DMEPOS due to the expiration of the
Covered when used with allowed
equipment’s RUL (reasonable use lifetime) or to loss, irreparable
E0470 or E0601*
damage, or when the item has been stolen.
Note: RA only needs to be appended to first month claim, and claims
should include a narrative explaining the reason for the replacement.
RR
DME Rental
*When ordered by treating physician and coverage criteria are met.
**If the supplier does not obtain information from the physician that the member has demonstrated improvement in
their OSA symptoms and is adhering to PAP therapy in time for submission of the fourth or succeeding
months’ claims, the supplier may still submit the claims, but a KX modifier must not be added.
Note:
CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS
codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).
Related Information
Definition of Terms
Adherence to therapy: The use of a PAP device for 4 or more continuous hours per night on
70% of nights during a consecutive thirty (30) day period anytime during the first three (3)
months/12 weeks of initial usage.
A claim submitted with the KX modifier is considered documentation of adherence (see
Documentation section).
Ineffective therapy: Defined as documented failure to meet therapeutic goals using a CPAP
device during the titration portion of a facility-based study or during home use despite optimal
therapy (i.e., proper mask selection and fitting and appropriate pressure settings).
Obstructive sleep apnea (OSA): A condition caused by obstruction of the upper airway.
Symptoms include repeated pauses in breathing during sleep and are usually associated with a
reduction in blood oxygen saturation.
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Polysomnogram: Also known as a “sleep study” is a diagnostic test for obstructive sleep apnea.
The patient is connected to a variety of monitoring devices that record at least 4 physiologic
variables while sleeping (e.g. heart rate, sleep/wake activity, blood oxygen saturation, respiratory
effort monitoring).
Titration of a PAP device: Testing that is done to find the right airflow pressure settings of the
equipment to keep the patient’s airway open yet allow the patient to sleep. The airflow pressure
of the PAP device is “titrated” (increased/decreased) to discover a single fixed pressure that
works for the individual. Titration can be done in the home setting using an auto-pap device.
For some individuals a facility based titration may be needed, the criteria for a facility basedtitration are outlined in related policy 2.01.503.
Evidence Review
Description
There are various types of positive airway pressure devices (i.e., fixed continuous positive airway
pressure [CPAP], bi-level positive airway pressure [BPAP], or auto-adjusting positive airway
pressure [APAP]).1 This policy only addresses the use of PAP devices for medical management of
obstructive sleep apnea (not central sleep apnea) after a sleep study and clinical evaluation
confirm the diagnosis. Sleep studies are addressed in a separate policy (see Related Policies).
CPAP involves the administration of air usually through the nose by an external device at a fixed
oxygen pressure to maintain the patency of the upper airway.
BPAP is similar to CPAP but these devices are capable of generating two adjustable pressure
levels that may be more comfortable for the patient compared to the fixed oxygen level.
ASV (adaptive servo-ventilation) is a form of bilevel positive airway pressure (BPAP) therapy that
is increasingly used to treat sleep-related breathing disorders, particularly central sleep apnea
(CSA). Similar to BPAP and CPAP, ASV provides expiratory positive airway pressure that can be
adjusted to control obstructive events. However, ASV therapy differs from CPAP or BPAP by
providing dynamic (i.e. breath-by-breath) adjustment of inspiratory pressure support and
utilizing an auto-backup rate to normalize breathing rate relative to a predetermined target.
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APAP adjusts the level of pressure based on the level of resistance, and thus administers a lower
mean level of positive pressure during the night. Both BPAP and APAP are considered by some
specialists to be more comfortable for the patient, and thus might improve usage compliance or
acceptance.
Rationale
Giles and colleagues reported that Cochrane reviews concluded that both CPAP and oral
appliances resulted in objective and subjective improvements in those with obstructive sleep
apnea.2 Thirty-six randomized trials involving 1,718 people met the inclusion criteria for
comparison of nocturnal CPAP with an inactive control or oral appliances in adults with
obstructive sleep apnea (defined as AHI greater than 5 per hour). The authors concluded that
CPAP is effective in reducing symptoms of sleepiness and improving quality of life measures in
people with moderate and severe obstructive sleep apnea. It is more effective than oral
appliances in reducing respiratory disturbances but subjective outcomes are more equivocal.
Certain people tend to prefer oral appliances to CPAP where both are effective. Short-term data
indicate that CPAP leads to lower blood pressure than control. Long-term data are required for
all outcomes in order to determine whether the initial benefits seen in short-term clinical trials
persist.
Skomro et al. (2010) published results of a randomized controlled trial with 102 subjects
consisting of home-based level 3 testing followed by 1 week of auto-CPAP and fixed-pressure
CPAP.3 The outcome measures were measured by daytime sleepiness (ESS), sleep quality
(Pittsburgh Sleep Quality Index {PSQI}), quality of life (Calgary Sleep Apnea Quality}, 36-Item
Short-Form Health Survey {SF-36}, BP, and CPAP adherence after 4 weeks. Their conclusions
stated that compared with the home-based protocol, diagnosis and treatment of OSA in the
sleep laboratory does not lead to superior 4-week outcomes in sleepiness scores, sleep quality,
quality of life, BP, and CPAP adherence.
In 2011, the Agency for Healthcare Research and Quality (AHRQ) conducted a comparative
effectiveness review (CER) on the diagnosis and treatment of OSA in adults.4 The review found
that based on the strength of the evidence that CPAP is rated as moderate for being an effective
treatment to alleviate sleep apnea signs and symptoms. The strength of the evidence that
mandibular advancement devices improve sleep apnea signs and symptoms was rated
moderate, and there was moderate evidence that CPAP is superior to mandibular advancement
devices in improving sleep study measures.
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There is a lack of studies on the use of ASV to treat obstructive sleep apnea. There are studies of
ASV for use in heart failure patients with central apnea or Cheyne-Strokes respiration. Therefore,
this device is considered investigational for the use in treatment of obstructive sleep apnea.
Practice Guidelines and Position Statements
American Academy Sleep Medicine (AASM)
In 2008, AASM published practice parameters5,6 on the use of APAP as detailed below:
1. APAP devices are not recommended to diagnose OSA;
2. Patients with congestive heart failure, patients with significant lung disease such as chronic
obstructive pulmonary disease; patients expected to have nocturnal arterial oxyhemoglobin
desaturation due to conditions other than OSA (e.g., obesity hypoventilation syndrome);
patients who do not snore (either naturally or as a result of palate surgery); and patients who
have central sleep apnea syndromes are not currently candidates for APAP titration or
treatment;
3. APAP devices are not currently recommended for split-night titration;
4. Certain APAP devices may be used during attended titration with polysomnography to
identify a single pressure for use with standard CPAP for treatment of moderate to severe
OSA;
5. Certain APAP devices may be initiated and used in the self-adjusting mode for unattended
treatment of patients with moderate to severe OSA without significant comorbidities (CHF,
COPD, central sleep apnea syndromes, or hypoventilation syndromes);
6. Certain APAP devices may be used in an unattended way to determine a fixed CPAP
treatment pressure for patients with moderate to severe OSA without significant
comorbidities (CHF, COPD, central sleep apnea syndromes, or hypoventilation syndromes);
7. Patients being treated with fixed CPAP on the basis of APAP titration or being treated with
APAP must have close clinical follow-up to determine treatment effectiveness and safety;
and
8. A re-evaluation and, if necessary, a standard attended CPAP titration should be performed if
symptoms do not resolve or the APAP treatment otherwise appears to lack efficacy.
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In 2016, AASM published updated recommendations for adaptive servo-ventilation in the
treatment of central sleep apnea syndromes in adults. There are no AASM recommendations for
the use of ASV for obstructive sleep apnea.
American College of Physicians (ACP)
The ACP 2013 Guidelines on the management of OSA in adults recommend that all overweight
and obese patients diagnosed with OSA should be encouraged to lose weight (strong
recommendation, low quality evidence).7 ACP recommends CPAP as initial therapy for patients
diagnosed with OSA (strong recommendation; moderate-quality evidence), and mandibular
advancement devices as an alternative therapy to CPAP for patients diagnosed with OSA who
prefer mandibular advancement devices or for those with adverse effects associated with CPAP
(weak recommendation, low-quality evidence). (See Related Policies)
Medicare National Coverage
There is no national coverage determination (NCD). In the absence of an NCD, coverage
decisions are left to the discretion of local Medicare carriers.
Regulatory Status
The use of CPAP devices are covered under Medicare when ordered and prescribed by the
licensed treating physician to be used in adults with OSA if either of the following criteria using
the AHI or RDI are met:

AHI or RDI of 15 events per hour or more, or

AHI or RDI between 5 and 14 events per hour with documented symptoms of excessive
daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented
hypertension, ischemic heart disease, or history of stroke.
Additional details of Medicare coverage and updates on PAP devices are available online.8
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References
1.
Noridian Administrative Services. Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L171)
Retired. DME Jurisdiction D.
https://med.noridianmedicare.com/documents/2230715/2240923/Positive+Airway+Pressure+%28PAP%29%20Devices
+for+the+Treatment+of+Obstructive+Sleep+Apnea.pdf/08a2de4c-c337-4a18-97e1-9f0d2e56e675 Accessed April 2017.
2.
Giles TL, Lasserson TJ, Smith BH et al. Continuous positive airways pressure for obstructive sleep apnea in adults. Cochrane
Database Syst Rev. 2006 Jul 19;3:CD001106.
3.
Skomro RP, Gjevre J, Reid J et al. Outcomes of home-based diagnosis and treatment of obstructive sleep apnea. Chest. 2010
Aug, 138(2):257.
4.
Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative
Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-100551) AHRQ
Publication No. 11-EHC052-EF. Rockville MD: Agency for Healthcare Research and Quality Jul 2011.
5.
Morgenthaler TI; Aurora RN; Brown T; et al. Standards of Practice Committee of the AASM. Practice parameters for the use of
auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive
sleep apnea syndrome: An update for 2007. SLEEP 2008;31(1):141-147. Available at:
http://www.aasmnet.org/Resources/PracticeParameters/PP_Autotitrating_Update.pdf Accessed April 2017.
6.
Kushida CA, Littner MR, Hirchkowitz M; et al. Practice parameters for the use of continuous and bi-level positive airway pressure
devices to treat adult patients with sleep-related breathing disorders. SLEEP 2006; (29) 3: 375-380. Available at:
http://www.aasmnet.org/Resources/PracticeParameters/PP_PositiveAirwayPressure.pdf Accessed April 2017.
7.
Qaseem A, Holty JE, Owens DK, et al. Management of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the
American College of Physicians. Ann Intern Med. Sept 2013; 159(7):471-83. Available at:
http://annals.org/article.aspx?articleid=1742606 Accessed April 2017.
8.
Centers for Medicare and Medicaid Services (CMS). National coverage determination for continuous positive airway pressure
(CPAP) therapy for obstructive sleep apnea (OSA); 240.4. Available at:
http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf Accessed April 2017.
9.
BlueCross BlueShield Association (BCBSA). Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome. Medical
Policy Reference Manual, Policy No. 2.01.18, 2015
History
Date
Comments
10/09/12
New DME policy. Information on CPAP extracted from 2.01.503 to create this policy.
The policy has a 90-day hold for provider notification and is effective 2/11/13.
01/24/13
Removed code E0471. Revised description of continued coverage with modifiers.
08/15/13
Update Related Policies. Change policy title to 2.01.503.
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∞
Date
Comments
09/11/13
Update Related Policies. Add 1.01.526.
10/16/13
Update Related Policies. Change policy title to 2.01.503.
01/21/14
Revised. Added modifier RA and explanation for use. Clarified replacement language.
Clarified continued coverage language.
07/14/14
Interim update. Added titration information. Added Nasal Expiratory Positive Airway
Pressure Device and Oral Pressure (Winx) Device information. Policy will be effective
October 23, 2014 to correspond with updates to 2.01.532 which are effective on that
date.
10/23/14
Reissue policy as updates are now effective; previous version removed from websites.
12/17/14
Coding update. HCPCS code E0471 added to the policy. No other changes.
04/14/15
Annual Review. Policy reviewed with literature search through February 2015. Policy
extensively rewritten and reformatted for usability. Policy statements simplified with
removal of detailed criteria about the apnea hypoxia index (AHI) and respiratory
disturbance index (RDI). Policy Guidelines reformatted and rewritten for ease of use;
Purchase and Repair subsections added. Coding table removed from Policy Guidelines.
Medicare NCD information added. Reference 6, 7, 8 added; others renumbered. Policy
statements simplified as noted.
06/02/15
Update Related Policies. Change title to 2.01.532.
08/11/15
Interim Update. Re added Table of supplies/accessory replacement frequencies.
Removed information on PAP device initiation with titration and placed in policy
2.01.503.
01/12/16
Annual Review. Simplified policy guidelines by removing extra statement on
replacement of a patient-owned PAP device during the 5 year RUL.
07/01/16
Interim Update, changes approved June 14, 2016. Added Adaptive Cervo Ventilation
and clarified rental period.
01/01/17
Interim review, changes approved December 13, 2016. Added clarifying policy
statement. Accessory add-ons and upgrades of an existing PAP device is considered
not medically necessary when a current PAP device is functional and meets the
member’s current basic functional medical needs.
03/30/17
Policy moved into new format; no change to policy statements.
05/01/17
Annual Review, changes approved April 11, 2017. Policy section rewritten for
clarification, better indicating adherence criteria. No changes to policy coverage.
Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The
Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and
local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review
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∞
and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit
booklet or contact a member service representative to determine coverage for a specific medical service or supply.
CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2017 Premera
All Rights Reserved.
Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when
determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to
the limits and conditions of the member benefit plan. Members and their providers should consult the member
benefit booklet or contact a customer service representative to determine whether there are any benefit limitations
applicable to this service or supply. This medical policy does not apply to Medicare Advantage.
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Discrimination is Against the Law
Premera Blue Cross complies with applicable Federal civil rights laws and
does not discriminate on the basis of race, color, national origin, age,
disability, or sex. Premera does not exclude people or treat them differently
because of race, color, national origin, age, disability or sex.
Premera:
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electronic formats, other formats)
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discriminated in another way on the basis of race, color, national origin, age,
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Civil Rights Coordinator - Complaints and Appeals
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Toll free 855-332-4535, Fax 425-918-5592, TTY 800-842-5357
Email [email protected]
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and Human Services, Office for Civil Rights, electronically through the
Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
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አማሪኛ (Amharic):
ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ Premera Blue
Cross ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ።
የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ
ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት
አለዎት።በስልክ ቁጥር 800-722-1471 (TTY: 800-842-5357) ይደውሉ።
‫( العربية‬Arabic):
‫ قد يحوي ھذا اإلشعار معلومات مھمة بخصوص طلبك أو‬.‫يحوي ھذا اإلشعار معلومات ھامة‬
‫ قد تكون ھناك تواريخ مھمة‬.Premera Blue Cross ‫التغطية التي تريد الحصول عليھا من خالل‬
‫ وقد تحتاج التخاذ إجراء في تواريخ معينة للحفاظ على تغطيتك الصحية أو للمساعدة‬.‫في ھذا اإلشعار‬
‫ اتصل‬.‫ يحق لك الحصول على ھذه المعلومات والمساعدة بلغتك دون تكبد أية تكلفة‬.‫في دفع التكاليف‬
800-722-1471 (TTY: 800-842-5357)‫بـ‬
中文 (Chinese):
本通知有重要的訊息。本通知可能有關於您透過 Premera Blue Cross 提交的
申請或保險的重要訊息。本通知內可能有重要日期。您可能需要在截止日期
之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母
語得到本訊息和幫助。請撥電話 800-722-1471 (TTY: 800-842-5357)。
037338 (07-2016)
Oromoo (Cushite):
Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa
yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee
odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa
ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf
yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan
jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin
odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu.
Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa.
Français (French):
Cet avis a d'importantes informations. Cet avis peut avoir d'importantes
informations sur votre demande ou la couverture par l'intermédiaire de
Premera Blue Cross. Le présent avis peut contenir des dates clés. Vous
devrez peut-être prendre des mesures par certains délais pour maintenir
votre couverture de santé ou d'aide avec les coûts. Vous avez le droit
d'obtenir cette information et de l’aide dans votre langue à aucun coût.
Appelez le 800-722-1471 (TTY: 800-842-5357).
Kreyòl ayisyen (Creole):
Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a kapab genyen
enfòmasyon enpòtan konsènan aplikasyon w lan oswa konsènan kouvèti
asirans lan atravè Premera Blue Cross. Kapab genyen dat ki enpòtan nan
avi sila a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka
kenbe kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo.
Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a,
san ou pa gen pou peye pou sa. Rele nan 800-722-1471
(TTY: 800-842-5357).
Deutsche (German):
Diese Benachrichtigung enthält wichtige Informationen. Diese
Benachrichtigung enthält unter Umständen wichtige Informationen
bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera
Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser
Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln
müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten
zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in
Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471
(TTY: 800-842-5357).
Hmoob (Hmong):
Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum
tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv
thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue
Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv
no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub
dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj
yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob
ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau
ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471
(TTY: 800-842-5357).
Iloko (Ilocano):
Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a
pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion
maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue
Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar.
Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti
partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti
salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti
daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti
bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357).
Italiano (Italian):
Questo avviso contiene informazioni importanti. Questo avviso può contenere
informazioni importanti sulla tua domanda o copertura attraverso Premera
Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe
essere necessario un tuo intervento entro una scadenza determinata per
consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di
ottenere queste informazioni e assistenza nella tua lingua gratuitamente.
Chiama 800-722-1471 (TTY: 800-842-5357).
日本語 (Japanese):
この通知には重要な情報が含まれています。この通知には、Premera Blue
Cross の申請または補償範囲に関する重要な情報が含まれている場合があ
ります。この通知に記載されている可能性がある重要な日付をご確認くだ
さい。健康保険や有料サポートを維持するには、特定の期日までに行動を
取らなければならない場合があります。ご希望の言語による情報とサポー
トが無料で提供されます。800-722-1471 (TTY: 800-842-5357)までお電話
ください。
Română (Romanian):
Prezenta notificare conține informații importante. Această notificare
poate conține informații importante privind cererea sau acoperirea asigurării
dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie
în această notificare. Este posibil să fie nevoie să acționați până la anumite
termene limită pentru a vă menține acoperirea asigurării de sănătate sau
asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste
informații și ajutor în limba dumneavoastră. Sunați la 800-722-1471
(TTY: 800-842-5357).
한국어 (Korean):
본 통지서에는 중요한 정보가 들어 있습니다. 즉 이 통지서는 귀하의 신청에
관하여 그리고 Premera Blue Cross 를 통한 커버리지에 관한 정보를
포함하고 있을 수 있습니다. 본 통지서에는 핵심이 되는 날짜들이 있을 수
있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기
위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다.
귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는
권리가 있습니다. 800-722-1471 (TTY: 800-842-5357) 로 전화하십시오.
Pусский (Russian):
Настоящее уведомление содержит важную информацию. Это
уведомление может содержать важную информацию о вашем
заявлении или страховом покрытии через Premera Blue Cross. В
настоящем уведомлении могут быть указаны ключевые даты. Вам,
возможно, потребуется принять меры к определенным предельным
срокам для сохранения страхового покрытия или помощи с расходами.
Вы имеете право на бесплатное получение этой информации и
помощь на вашем языке. Звоните по телефону 800-722-1471
(TTY: 800-842-5357).
ລາວ (Lao):
ແຈ້ ງການນ້ີ ມີຂ້ໍ ມູ ນສໍາຄັ ນ. ແຈ້ ງການນ້ີ ອາດຈະມີຂ້ໍ ມູ ນສໍາຄັ ນກ່ ຽວກັ ບຄໍາຮ້ ອງສະ
ໝັ ກ ຫື ຼ ຄວາມຄຸ້ ມຄອງປະກັ ນໄພຂອງທ່ ານຜ່ ານ Premera Blue Cross. ອາດຈະມີ
ວັ ນທີສໍາຄັ ນໃນແຈ້ ງການນີ້. ທ່ ານອາດຈະຈໍາເປັນຕ້ ອງດໍາເນີນການຕາມກໍານົ ດ
ເວລາສະເພາະເພື່ອຮັ ກສາຄວາມຄຸ້ ມຄອງປະກັ ນສຸ ຂະພາບ ຫື ຼ ຄວາມຊ່ ວຍເຫື ຼ ອເລື່ອງ
ຄ່ າໃຊ້ ຈ່ າຍຂອງທ່ ານໄວ້ . ທ່ ານມີສິດໄດ້ ຮັ ບຂ້ໍ ມູ ນນ້ີ ແລະ ຄວາມຊ່ ວຍເຫື ຼ ອເປັນພາສາ
ຂອງທ່ ານໂດຍບໍ່ເສຍຄ່ າ. ໃຫ້ ໂທຫາ 800-722-1471 (TTY: 800-842-5357).
ភាសាែខម រ (Khmer):
េសចកត ីជូនដំណឹងេនះមានព័ត៌មានយា៉ងសំខាន់។ េសចកត ីជូនដំណឹងេនះរបែហល
ជាមានព័ត៌មានយា៉ងសំខាន់អំពីទរមង់ែបបបទ ឬការរា៉ប់រងរបស់អនកតាមរយៈ
Premera Blue Cross ។ របែហលជាមាន កាលបរ ិេចឆ ទសំខាន់េនៅកនុងេសចកត ីជូន
ដំណឹងេនះ។ អន ករបែហលជារតូវការបេញច ញសមតថ ភាព ដល់កំណត់ៃថង ជាក់ចបាស់
នានា េដើមបីនឹងរកសាទុកការធានារា៉ប់រងសុខភាពរបស់អនក ឬរបាក់ជំនួយេចញៃថល ។
អន កមានសិទធិទទួ លព័ត៌មានេនះ និងជំនួយេនៅកនុងភាសារបស់អនកេដាយមិនអស
លុយេឡើយ។ សូ មទូ រស័ពទ 800-722-1471 (TTY: 800-842-5357)។
ਪੰ ਜਾਬੀ (Punjabi):
ਇਸ ਨੋਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨੋਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ ਤੁਹਾਡੀ
ਕਵਰੇਜ ਅਤੇ ਅਰਜੀ ਬਾਰੇ ਮਹੱ ਤਵਪੂਰਨ ਜਾਣਕਾਰੀ ਹੋ ਸਕਦੀ ਹੈ . ਇਸ ਨੋਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ
ਹੋ ਸਕਦੀਆਂ ਹਨ. ਜੇਕਰ ਤੁਸੀ ਜਸਹਤ ਕਵਰੇਜ ਿਰੱ ਖਣੀ ਹੋਵੇ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱ ਚ ਮਦਦ ਦੇ
ਇਛੁੱ ਕ ਹੋ ਤਾਂ ਤੁਹਾਨੂੰ ਅੰ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁੱ ਝ ਖਾਸ ਕਦਮ ਚੁੱ ਕਣ ਦੀ ਲੋ ੜ ਹੋ ਸਕਦੀ ਹੈ ,ਤੁਹਾਨੂੰ
ਮੁਫ਼ਤ ਿਵੱ ਚ ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱ ਚ ਜਾਣਕਾਰੀ ਅਤੇ ਮਦਦ ਪ੍ਰਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ
800-722-1471 (TTY: 800-842-5357).
‫( فارسی‬Farsi):
‫اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم‬. ‫اين اعالميه حاوی اطالعات مھم ميباشد‬
‫ به تاريخ ھای مھم در‬.‫ باشد‬Premera Blue Cross ‫تقاضا و يا پوشش بيمه ای شما از طريق‬
‫شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه‬. ‫اين اعالميه توجه نماييد‬
‫شما حق‬. ‫ به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد‬،‫ھای درمانی تان‬
‫ برای کسب‬.‫اين را داريد که اين اطالعات و کمک را به زبان خود به طور رايگان دريافت نماييد‬
‫( تماس‬800-842-5357 ‫ تماس باشماره‬TTY ‫ )کاربران‬800-722-1471 ‫اطالعات با شماره‬
.‫برقرار نماييد‬
Polskie (Polish):
To ogłoszenie może zawierać ważne informacje. To ogłoszenie może
zawierać ważne informacje odnośnie Państwa wniosku lub zakresu
świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na
kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie
przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub
pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej
informacji we własnym języku. Zadzwońcie pod 800-722-1471
(TTY: 800-842-5357).
Português (Portuguese):
Este aviso contém informações importantes. Este aviso poderá conter
informações importantes a respeito de sua aplicação ou cobertura por meio
do Premera Blue Cross. Poderão existir datas importantes neste aviso.
Talvez seja necessário que você tome providências dentro de
determinados prazos para manter sua cobertura de saúde ou ajuda de
custos. Você tem o direito de obter esta informação e ajuda em seu idioma
e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357).
Fa’asamoa (Samoan):
Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau
ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala
atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua
atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei
fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le
aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai
i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua
atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i
ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471
(TTY: 800-842-5357).
Español (Spanish):
Este Aviso contiene información importante. Es posible que este aviso
contenga información importante acerca de su solicitud o cobertura a
través de Premera Blue Cross. Es posible que haya fechas clave en este
aviso. Es posible que deba tomar alguna medida antes de determinadas
fechas para mantener su cobertura médica o ayuda con los costos. Usted
tiene derecho a recibir esta información y ayuda en su idioma sin costo
alguno. Llame al 800-722-1471 (TTY: 800-842-5357).
Tagalog (Tagalog):
Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang
paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon
tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue
Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring
mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang
panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na
walang gastos. May karapatan ka na makakuha ng ganitong impormasyon
at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471
(TTY: 800-842-5357).
ไทย (Thai):
ประกาศนี ้มีข้อมูลสําคัญ ประกาศนี ้อาจมีข้อมูลที่สําคัญเกี่ยวกับการการสมัครหรื อขอบเขตประกัน
สุขภาพของคุณผ่าน Premera Blue Cross และอาจมีกําหนดการในประกาศนี ้ คุณอาจจะต้ อง
ดําเนินการภายในกําหนดระยะเวลาที่แน่นอนเพื่อจะรักษาการประกันสุขภาพของคุณหรื อการช่วยเหลือที่
มีค่าใช้ จ่าย คุณมีสิทธิที่จะได้ รับข้ อมูลและความช่วยเหลือนี ้ในภาษาของคุณโดยไม่มีค่าใช้ จ่าย โทร
800-722-1471 (TTY: 800-842-5357)
Український (Ukrainian):
Це повідомлення містить важливу інформацію. Це повідомлення
може містити важливу інформацію про Ваше звернення щодо
страхувального покриття через Premera Blue Cross. Зверніть увагу на
ключові дати, які можуть бути вказані у цьому повідомленні. Існує
імовірність того, що Вам треба буде здійснити певні кроки у конкретні
кінцеві строки для того, щоб зберегти Ваше медичне страхування або
отримати фінансову допомогу. У Вас є право на отримання цієї
інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за
номером телефону 800-722-1471 (TTY: 800-842-5357).
Tiếng Việt (Vietnamese):
Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông
tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua
chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông
báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn
để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có
quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình
miễn phí. Xin gọi số 800-722-1471 (TTY: 800-842-5357).