Provider Notices

Alternative Care Visit Limits/Determination – alignment across all therapy modalities.

8/27/2018 6:20:16 AM

Effective July 27, 2018, in order to bring consistency in the review of medical necessity criteria in determining the number of visits for all therapy modalities, MCG (formerly Milliman Care Guidelines) evidence-based guidelines and Guidelines Note 6 and 56 (from OHA’s Prioritized List of Health Services) are being used. MCG will be used to determine the appropriate number of visits per condition for all treatment modalities (including chiropractic/acupuncture).

  • Initial visit requests will be determined based on MCG.

  • Subsequent visit requests will be determined based on medical appropriateness with documented support. MCG and GN 6 and 56 will be used as applicable to determine appropriateness (includes OHA’s 30-visit limit).

Please call PacificSource with any questions regarding this change.