Corrections need to be made to the primary claim as these claims are crossed over. If you correct the Medicaid claim only and the services are covered by Medicare or Commercial, this claim will erroneously create a new Medicare or Commercial claim for processing.
Claims are crossed over from PacificSource Medicare and PacificSource Commercial to PacificSource Community Solutions for Coordination of Benefits.
In order to better align with the Oregon Health Authority, effective February 1, 2021 Pacificsource Community Solutions will now allow retro pre-approval requests for up to 90 days from the date of service.
Pre-approvals may be given a past date of service if:
The member was made retroactively eligible or was retroactively disenrolled from a CCO or PHP on the date of service.
The provider has not already billed for the service and/o
Our NEMT brokerage ModivCare formally known as LogistiCare is operating under Inclement Weather Conditions in some areas of Oregon.
Please know that they are prioritizing those appointments that are considered critical care – e.g. dialysis, chemo, radiation therapy, etc. In addition they are also working to reroute those and/or reschedule others that are non-critical care.
In April of 2018, PacificSource implementing a new process for claims research requests from providers. That pertain to all Medicare and Medicaid claim requests.
Formerly, a provider could reach out to the Provider Service Representative and request a correction or review of a claim discrepancy.
The process that was implement created a uniform approach for providers requiring all requests be sent to the claim research mailbox at:
PacificSource Community Solutions (PSCS) no longer requires referrals for Medicaid members to see a specialist effective 1/1/2021. We have created a quick reference FAQ for our providers to help with the transition.
Effective February 25, 2021, the following code will require a Prior Authorization.
Please call PacificSource with any questions regarding this change.
PacificSource COVID-19 Benefit and Reimbursement FAQ - Updated January 2021
PacificSource Health Plans is dedicated to meeting the needs of our members, including the ability to locate appropriate care. Toward this goal, we are pleased to introduce a new partnership regarding provider data validation to better our Provider Directory. This partnership with BetterDoctor was effective January 2021.
Effective January 1, 2021 the following codes have been removed from our Prior Authorization grid. Every year prior authorization requirements are subject to change; some codes are added while others are removed. Please see our Prior Authorization grid to confirm whether a service requires a prior authorization.
PacificSource does not require the vaccine CPT to be billed, as the vaccines are supplied by the government.
PacificSource is responsible for meeting standards for multiple federal and state regulations as well as accrediting standards and fulfilling obligations of contracts with various groups. As a contracted entity of PacificSource, you are also responsible for complying with these requirements and must ensure your contracted entities comply with applicable laws and regulations. . If you currently utilize or plan to work with an offshore subcontractor that uses member pr
All Community Solutions (Medicaid) claims with 2021 dates of service are being held while we validate correct pricing and benefit configuration. We anticipate these claims will be released by January 25, 2021.
The Oregon Health Authority has updated its Oregon Medicaid provider enrollment requirements to include an additional form called "Provider Enrollment Agreement." The following Provider Enrollment Agreement will take effect with OHA starting January 1st. Any applications received December 14th and after, we ask that we collect the Provider Enrollment Agreement to help with a seamless transition into the new year.
Pharmacy Coverage Updates Effective February 15, 2021
Expand your knowledge in tele-mental health services
Designed for providers and clinicians across the spectrum of behavioral health, this workshop series provides step-by-step instructions on setting up a tele-mental health practice with insights on best practices for client care, administration, and ethics in virtual care. Plus, get answers to your questions about developing a comprehensive tele-mental health practice.
We will be updating our prior authorization list effective for dates of service on or after January 1, 2021. Please review the summary of these changes below.
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a highly rated, evidence-based therapy designed to treat children ages 3-17 with an array of trauma histories, including children with multiple and complex traumas in their lives.
Pharmacy Coverage Updates Effective December 15, 2020
Pharmacy Coverage Updates Effective November 15, 2020
The THW Liaison team is available to support the integration and utilization of THWs (birth doulas, personal health navigators, peer support specialists, youth support specialists, family support specialists, peer wellness specialists and community health workers). Working in partnership with the Provider Services team, the Liaisons can assist THWs with Oregon Health Authority (OHA) approved training, OHA THW certification, best practices and other technical assistance.
We have noticed an increased number of providers submitting duplicate claims days apart from each other. This duplicate volume significantly impacts the workflow resulting in delays.
Pharmacy Coverage Updates Effective 09/15/2020
Updates to AIM Advanced Imaging Clinical Appropriateness Guideline
Medicaid Provider Stability Payments
In collaboration with the Oregon Health Authority, PacificSource is in the process of issuing provider stability payments to support providers who serve our CCO members and who rely on fee-for-service payments from PacificSource. This is intended to offset financial impacts on providers due to the COVID-19 pandemic.
PacificSource Community Solutions is working to support our members and communities during this pandemic. We have implemented the following to support providers in this time of uncertainty:
Eased operational burdens on providers
Expanded telehealth billing policies
Distributed early payments under 2019 risk arrangements
Distributed 2019 quality incentive “early release” funds made available by
Provider Relief Plan
On behalf of OHA we are sharing this information to keep our providers informed and current with any changes made. This Information is specific to Oregon Health Plan physical and behavioral health providers.
COVID-19 Emergency Declaration Health Care Providers Fact Sheet
Billing Dual Covered Members - PacificSource Medicare Advantage and Community Solutions