Web Content Viewer (JSR 286)

PAP Compliance


1. Patient PAP Usage Reporting

Click here to navigate to the PAP Usage Reporting site.

2. Forms

Liability Acknowledgement Form for Anthem Members: Due to changes in Anthem’s sleep therapy management program, patients are now required to document ongoing usage of or continued therapeutic benefits from their PAP device every 90 days. Failure to comply with these requirements may mean that the insurer will refuse to authorize (or pay for) the patient’s PAP equipment. A signature on this document signifies your agreement to be financially responsible for your PAP equipment should you fail to meet the requirements. Please sign the Anthem Advance Beneficiary Notice of Non-coverage below and fax it to the requesting Branch, Customer Care Center or Billing Center. 
Note: If you are a patient living in the state of Colorado, please use form 2.2 below.

2.1 Anthem Home Plan Patients (Non-Medicare Advantage in CO, GA, IN, KY, MO, NV, OH and WI)

RMSD-00181 ABN Possible Non-coverage Anthem PAP

2.2 Anthem Home Plans for Colorado Medicare Advantage Patients

RMSD-00188 ABN Colorado Medicare Advantage

2.3 Anthem Home Plans for California Patients

RMSD-00189 Anthem Blue Cross Individual Patient Responsibility Waiver


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