Effective November 1, 2018 PacificSource Community Solutions will be requiring a reassessment tool of members pain for authorizations requesting subsequent therapy visits for back or spine conditions.
Guideline Note 56 of the OHP Prioritized List of Health Services states “documentation of measurable clinically significant progress toward the therapy plans of care goals and objectives using evidence based objective tools”. Accepted tools are the Keele STarT Back Tool, Neck Disability Index or Oswestry Disability Index. The reassessment tool will be compared to the initial assessment to determine medical appropriateness. Requesting more visits without these tools will be subject to a denial. This includes all PT, OT, Chiropractic, OMT and Acupuncture therapies.
Initial visit requests will be determined based on MCG (Milliman Care Guidelines).
Subsequent visit requests will be determined based on medical appropriateness with documented support including an objective tool per Guideline Note 56.
Links to tools: