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Provider Notices

OHA has recently updated the fee-for-service payment rates, and also included a new enhanced wage add-on rate for approved nursing facilities effective 10/1/2021. Those who qualify will be notified and have a specialty code added to the facility’s Oregon Medicaid provider number that allows billing for the enhanced rate. Read the full OHA notice here https://www.oregon.gov/oha/HSD/OHP/Announcements/Hospice-Rates1

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Pharmacy Coverage Updates Effective March 15, 2022



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PacificSource Community Solutions Claims Pay Hold Effective January 1, 2022

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Prior Authorization required for Transcranial Magnetic Stimulation (TMS) Effective February 1, 2022



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Pharmacy Coverage Updates Effective January 1, 2022



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Effective 1/1/2022, prior authorization requirements will remain on Neuropsychological codes.  A prior authorization requirement will be added to code 93137 Psych or neuropsych test, addl. 

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According to an OHA CCO Contract change in 2022 providers offering ACT services will be required to submit a notification though the InTouch Portal.

 



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We wanted to pass along an enhancement to the PCP Enrollment Listing report that is available to all PCP providers via InTouch (InTouch > Reports > PCP Enrollment Listing).

This report now identifies member language and interpreter needs, including Sign Language needs.   For more information on our Community Solutions approved Interpreter Vendors, see our  Read More

Philips CPAP/BiPAP Recall Information

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Changes to Notification Requirements for Assertive Community Treatment (ACT) Services



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Effective 12/01 2021, members admitted to an Acute Inpatient Hospital where payment is based on a DRG (diagnosis related group): 

Approved initial inpatient reviews will be authorized for a DRG payment rather than a goal length of stay. This will eliminate routine concurrent reviews. After the claim is received and before payment is made, outlier payment requests will be reviewed for medical necessity.

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2022 Medicaid Authorization Grid Updates - Effectve 1/1/2022

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We have updated the below notice to reflect the updated name for ‘Board Registered Interns’ to the correct name effective August 6, 2021, to ‘Board Registered Associates’ per Oregon State Legislation.

The below notice is still current. The only change made is relative to the Oregon State Legislation, implementing the immediate name change.

 



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Update as of August 30th 2021- RideSource also known as Lane Transit District’s (LTD) our NEMT brokerage in Lane County is operating under regular capacity. 



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Medicaid Grievance and Appeals Policy Guidance

These documents contain policy guidance for Member Information and Education Requirements, Notice of Adverse Benefit Determination, Grievances Appeals and Hearing policy and guidance. 



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Pharmacy Coverage Updates Effective October 15, 2021



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211 will be available to Oregonians for help with heat-related resources, including locating a cooling center. All Oregon counties have been asked to send cooling center information to 211 for inclusion on the website, which is available in seven languages: https://www.211info.org/coolingcenters. Here is a list of additional resources for you and

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This box is used to report the onset of acute symptoms for a current illness or condition or that the services are related to the patient’s pregnancy.  There are two valid qualifiers for this box, these qualifiers and their guidelines are listed below.



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Effective 8/2/2021, MRI prior authorization requirements will be removed. Please see the below MRI CPT codes that will not require a prior authorization.

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Effective 8/2/2021, prior authorization requirements will be removed. Please see the below CPT codes that will not require a prior authorization.

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Effective 8/2/2021, prior authorization requirements will be removed for PT/OT/ST and Alternative Services. As a reminder, prior authorizations are always required for out-of-network providers.



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Effective 8/1/2021, Board Registered Interns will be required to bill PacificSource Community Solutions under their own name, NPI and Medicaid ID. Previously, these practitioners were required to bill under their supervisor as incident to.

This applies to: a) Psychologist Associate Residents as described in OAR 858-010-0037; (b) Licensed Psychologist Associate under continued supervision as described in OAR 858-010-0038; (c) Licensed Professional Counselor intern or Marriage and Fam

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On  May 5, 2021 date we released the below notice. At this point in time 6/25/21, the below guidance is incorrect and prior requirements will remain unchanged until further notice . We apologize for any inconvenience this has caused.

Should you have any claims impacted betweens dates of service 6/6/21 - 6/25/21, please contact your Provider Service Representative.

 

Effective 6/6/2021, prior authorization requirements will be removed for the follo

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Dear Providers,

On behalf of the Oregon Health Authority, we include the below link to the Model Standing Order and Immunization Protocol for COVID-19 vaccinations. Please visit the link for details regarding important updates.

https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/VACCINESIMMUNIZATION

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Board Registered Interns will be required to bill PacificSource Community Solutions under their own name, NPI and Medicaid ID, effective 8/1/2021. Previously, these practitioners were required to bill under their supervisor as incident to.



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Updated Prior Authorization (PA) requirement for code 81479

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Behavioral Health services – Removal of Prior Authorization requirements and related submission changes



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Pharmacy Coverage Updates Effective July 15, 2021



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AIM Specialty Health portal user guide

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Effective 6/1/2021 a PA will be required on the following DME codes:
L3900, L3901, L3904, L3905 and A7020.
 


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Effective 1/1/21 prior authorization is not be required for transfers to skilled nursing facilities, inpatient rehabilitation centers, and long term acute care hospitals. However, we do require inpatient notification as our Health Services team is performing concurrent review and will require updated notes for continued stay

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On behalf of OHSU please see the below links for additional resources around the Oregon Psychiatric Access Line (OPAL). This program is offering psychiatric telephone consultations to health care providers in Oregon.   


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Primary Care Provider Capacity and Member Panel Changes an Reporting Requirement  Reminders 

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Medicaid Preauthorization (PA) requirements change for Cardiovascular Monitors 

Effective 5/20/2021, PacificSource will not be requiring a PA with the associated codes:

  • 93229 Wearable Mobile Cardiovascular Telemetry with Events Transmitted To Center for up to  30 Days; Technical Support
  • 93228 Wearable Mobile Cardiovascular Telemetry with Events Transmitted To Center for up to 30 Days; Physician Review W Report

 



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According to a OHA CCO Contract change in 2021 a prior authorization will be required for ECT treatment effective May 23, 2021.  This contract change applies to CPT code 90870.



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For dates of service on or after March 15, 2021, PacificSource Health Plans will utilize GPCI adjusted rates to determine allowables for COVID vaccine administration.

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Medicaid Genetic Testing Prior Authorization Requests

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Please see Oregon Health Authorities (OHA) billing guidance on COVID-19 Vaccines.

https://www.oregon.gov/oha/HSD/OHP/Tools/OHP-Vaccine-Fact-Sheet.pdf

Please Note: Providers not contracted with the CCO should bill OHA (COVID-19 Vaccines), see link for full details.



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Pharmacy Coverage Updates Effective May 15, 2021



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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.



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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

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Dear Provider’s

 

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.

 



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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: 



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Dear Providers,

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.



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Effective February 25, 2021, the following code will require a Prior Authorization. 

  • 64568 Incision for Implantation of Cranial Nerve (Eg, Vagus Nerve) Neurostimulator Electrode Array and Pulse Generator.

Please call PacificSource with any questions regarding this change. 



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PacificSource COVID-19 Benefit and Reimbursement FAQ - Updated January 2021



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