COVID-19 vaccine news for Oregon Health Plan members
Learn more

Provider Notices

2021 Medicaid Referral Removed FAQ

2/4/2021 3:39:35 PM

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.

***Please note out of network providers will still require prior authorization***

 

Member Eligibility and Benefits:

Providers must check a member's eligibility and benefits prior to rendering care. A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service. 

 

Prior Approval:

What is the difference between a referral and a pre-approval?

A "referral" is the process by which the member's primary care provider (PCP) directs them to obtain care for covered services from other health professionals in an office setting.

A "pre-approval" is defined as a request for a specific service that requires review to determine medical necessity. Services that require pre-approval are outlined on our website at CommunitySolutions.

 

When is it necessary to submit a pre-approval?

•Medical necessity

•Coverage limitations

To determine if a service and or medication requires pre-approval, consult our Prior Authorization Grid (Authgrid.PacificSource.com). If the service requires pre-approval when done in person, then pre-approval is required when done as telehealth. Medication coverage status and pre-approval requirements by line of business can be found on our PA Grid that can be found https://authgrid.pacificsource.com/#

How do I know if a service is covered under the Oregon Health Plan (OHP)? This can be identified by using LineFinder. LineFinder is an online tool to assist providers in determining what is covered by OHP. OHP generally updates the information quarterly Linefinder tool can be found https://intouch.pacificsource.com/LineFinder

 

Is a pre-approval a guarantee of payment for services?

No. Payment for services is always subject to:

•Medical necessity,

•Member eligibility on the date(s) of service, and

• Member's benefits as defined in their plan conditions, terms, and limitations.

To determine if your patient's condition is covered by OHP, check LineFinder.

 

What information is required when submitting a pre-approval request?

•Member name, date of birth, and member ID number

•Referring provider information and contact information

•Treating provider or facility name and contact information

•Diagnosis code(s)

•Number of visits

•Type of service

•Start date of request and timeframe (start and end dates must be clearly defined)

•Chart notes are always required- Referring provider and/or PCP chart notes are acceptable if patient has yet to establish care with your office.

•Current evaluation, re-evaluation and/or progress notes

• Alternative Care: Supporting documentation that outlines the type of care being requested (maybe from referring provider or primary care provider).

For Alternative Care and Traditional Therapy are Pre-approvals required?

Yes, pre- approval standards have not changed for these services. Please see above section that outlines what information is required when submitting a pre-approval request.

What particular information about therapy should I be aware of?

•U.S. Department of Health and Human Services has deemed that chiropractic services are not appropriate for infants. Some exceptions may apply through a medical diagnosis.

•Children under the age of 14 should not be receiving chiropractic adjustments (also according to the U.S. Department of Health and Human Services). Some exceptions may apply through a medical diagnosis.

•A STarT Back Tool (SBT) is required beginning at the age of 14.

•If a member has received their 30 visits for physical therapy and is now submitting prior authorization for alternative therapy, it will be denied. The member has used their 30-visittotal for the year.

•Chiropractors may submit a prior authorization to another therapy, such as acupuncture or massage.

•Massage should not be asked for as a stand-alone service. Stand-alone massage is only covered for a back condition.

Below the Line Diagnoses:

Member eligibility and benefit requirements still apply

 

Please reference the below guide regarding the different guidelines for Primary Care and Specialty Care offices.

Primary Care Office Visits: Primary care claims will be allowed one Below-the-Line office visit to confirm a diagnosis. Office visit every 30 days for the same diagnosis code. This means that primary care clinics will be paid for the first Below-the-Line office visit to confirm a diagnosis. Any additional claims within 30 days showing the same diagnosis will be denied.

Specialty Care Office Visits:  PSCS allows one initial Below the Line (BTL) office visit by specialty. At least one Above the Line diagnosis is required for claims to process after the one initial BTL office visit has been used within a 12 month lookback. The first five diagnoses are reviewed If no ATL diagnosis is submitted, the claim will be denied if no prior authorization is in place. Prior-authorization requirements remain the same, office’s will need to submit a prior-authorization if a member presents for a BTL diagnosis or non- pairing.

 

What would be required to be included in a pre-approval request for a BTL office visit after our one initial BTL diagnosis exception has been used?

Please reference the above pre-approval section of what would need to be included. The best practice is to include all supporting documentation within the pre-approval process, including referring provider documentation.

Note: if a determination is made that you not in agreement with, you are able to appeal. For more information regarding our Appeals process, please visit our Provider Manual.

 

What if a member is presented with a BTL diagnosis office visit? Would I need to put in a pre-approval for the first visit?

Please see the above guidelines for Primary Care and Specialty Care offices.

 

What you need to know about Below the Line diagnoses:

• BTL is a non-covered diagnosis; the Line applies to all providers for all Medicaid services.

•The Line will not apply to laboratory or x-ray services. These services are diagnostic in nature. Please note that some laboratory and x-ray services are excluded by OHP (and were never covered, regardless of Line placement).

•ER and urgent care visits will be covered. The existing workflow will remain in place for inpatient stays, since those services require prior authorization.

•Our system will consider up to five diagnoses on any claim to allow for comorbidities. If any of the first five diagnoses are Above the Line, the claim will pay pursuant to the applicable contract arrangement. (The claims system will continue to accept more than five diagnoses per claim; this is particularly important for quality reporting purposes.)

• If none of the first five diagnoses are Above the Line, the claim will be evaluated as described in the next section.

•PacificSource will use the OHA-determined Line and the OHA Diagnostic Workup File (DWF) to determine coverage. (The DWF contains a number of diagnosis codes that pertain to symptoms. PacificSource is using the DWF to allow providers to make a diagnosis.)

• The process described above will also be applied to claims where Medicaid is the secondary payer.

 

What happens if a diagnosis falls Above and Below the Line?

Some diagnosis codes will show both Above and Below the Line. In these circumstances, a pre-approval would be required. A clinician will review and determine which Line the diagnosis should fall on. Chart notes will be required to make this determination.

 

 

Please reach out to our Provider Service team with questions at ORProviderService@pacificsource.com

 

 


Back