Printable PDF | Winter 2013

You Asked, We Listened: Eligibility Data Enhancements

Many of our providers use HDX® for the secure electronic exchange of eligibility information, and have asked us to enhance the eligibility data we send to them. You’ll be glad to know we recently made several of the requested changes, including more specific copay information, such as urgent care and mental health office visits; remaining (general) deductible amounts for both individual and family; and out-of-pocket maximum and remaining for both individual and family. More than 40 new service type codes have been added, and you'll see see specific service type accumulator data (where applicable to the member). Types of data  include:

• Deductible amount for both individual and family
• Remaining deductible for both individual and family 
• Benefit limit amount in dollars for both individual and family 
• Remaining benefit amount in dollars for both individual and family 
• Benefit limit amount in “visits” for both individual and family 
• Remaining benefit amount in “visits” for both individual and family 
• Time period (i.e., calendar year, plan year, lifetime) 

HDX (a division of Siemens Healthcare) supports insurance eligibility transactions (X12 270/271) with PacificSource Health Plans. For more information about HDX, call them at (866) 439-3341 or visit www.HDX.com.

InTouch Online Authorization Tools Now Even Easier to Use

This month, you may notice several improvements to our online authorizations tools. A popular feature of InTouch for Providers (our secure portal for participating providers), the authorizations area of the site allows you to submit and track medical prior authorizations, inpatient stay requests, and referral requests.

While the overall flow and functionality of the site is the same, we’ve fixed a few bugs and made some subtle changes to improve usability. A few examples: 

• Improved document handling
• Expanded searching and filtering options 
• Welcome page content organized into a user-friendly tab format 
• Larger text fields for notes, plus several new fields 
• Better indications regarding the status of web requests 
• New “Updates” method lets you submit additional text and documents regarding a specific web request 
• Shading on grids and input fields to improve readability

To learn more about InTouch and to register, visit the About InTouch for Providers web page.

If you have any questions or suggestions for further improvements to InTouch, please contact your PacificSource Provider Service Representative. We’re always looking for ways to make it easier for you to do business with us!

Standard Practice Guidelines Aid Health Decisions

To help providers and members make decisions about appropriate healthcare, we’ve adopted guidelines derived from nationally recognized sources. The guidelines are updated regularly and are available online at PacificSource.com/provider/practice-guidelines.aspx.

Currently, you will find links to guidelines for common conditions, including asthma, behavioral health and chemical dependency, CAD, COPD, diabetes, heart failure, obesity, and more. Immunization screening recommendations are also listed. The guidelines are based on recent medical evidence and/or consensus among physicians regarding clinical treatment patterns.

Please note that these guidelines are not intended to be a substitute for professional medical advice. Benefit determinations should always be based on the applicable contract coverage.

Stay Informed about Reform

In keeping with our mission of helping people get the healthcare they need, we continue to support access to effective, affordable healthcare for all Americans. Please visit our Healthcare Reform Resource Center for more information and to sign up to receive our Healthcare Reform eUpdate newsletter.

In the coming year as we prepare for the healthcare exchanges, we will be sending more frequent updates to help our members, employers, and providers know what to expect. If you have specific questions about reform, please feel free to contact your PacificSource Provider Representative.

HEDIS Reporting Requires Medical Record Collection

As part of our ongoing effort to improve healthcare outcomes in the communities we serve, we are again participating in Healthcare Effectiveness Data and Information Set (HEDIS) reporting. HEDIS reporting requires collection of medical records for specific patients, and we have contracted with a vendor, Outcomes Health, to help with that process.

If medical records for your patient are required, our vendor will contact you by mail to arrange for convenient collection of that information. You’ll be able to fax or email the records or arrange for them to be reviewed in your office—whichever option you prefer.

Under HIPAA privacy rules, disclosure of Protected Health information (PHI) is permitted for accreditation and certification activities, such as HEDIS reporting. These disclosures may be made to a business associate, acting on behalf of the covered entity. Please be assured that Outcomes Health has executed HIPAA-compliant business associate agreements to perform the medical record reviews.

We appreciate your support with this important quality improvement initiative.

Condition Support Newsletters Mailed 

In early November, we mailed the first issues of Real Life, our new Condition Support program newsletter, to PacificSource members enrolled in one of our five Condition Support programs. The two-page, quarterly newsletters include tips and helpful information for members living with diabetes, coronary artery disease, heart failure, COPD, and asthma.

You can read the newsletters and find out more about our Condition Support Programs at Pacificsource.com/member/condition-support-program/.

Administrative News and Reminders

Fines Increased for Incorrect W9 Tax Forms

Tax time is just around the corner. Please make sure the W9 form you submit to us matches what you send to the IRS. For 2013, the IRS has doubled the fine to insurance carriers—from $50 to $100 per incorrect W9 form. These fines are part of our administrative costs, which have a direct impact on our rates. By assisting us in keeping fines low, you’re ultimately helping to control healthcare costs for your patients.

Coordination of Benefits and Secondary Claims

Several months ago, we programmed our claims system to automatically create secondary claims for members who have more than one PacificSource plan (any combination of commercial, PacificSource Administrators, and Medicare Advantage policies). With the new process, there is often up to a one-week gap between the payments of the two claims. This extra time is necessary to ensure the secondary claim is paid correctly.

If the primary and secondary claims are not on the same explanation of payment (EOP), please wait until you receive your next EOP to see if the secondary processing is there. If not, you may contact our Customer Service Department at (888) 977-9299 to check the claim status. If for some reason the claim was not processed under the secondary plan, we can take care of it over the phone, and there is no need to rebill. Thanks for your cooperation!

Verifying Provider Eligibility Helps Patients Avoid Unexpected Medical Costs

To maintain a high level of service to our members, we require all providers rendering services to our members be credentialed. Some provider types are considered ineligible due to licensure, lack of a governing body, or education limitations. If a member receives care from a provider considered ineligible by PacificSource, there will be no reimbursement for services rendered.

Some examples of commonly used ineligible providers are surgical technicians (when practicing independently) and intraoperative monitoring technicians. Please note that these are just examples. If you are partnering with a provider outside your practice, please ensure they are eligible for reimbursement. If found to be ineligible, we ask that you notify the patient accordingly.

If you have questions about provider eligibility, please reference our Provider Manual or contact your Provider Service Representative.

Major Changes to Psychiatry CPT Codes for 2013

As you may know, the Relative Value Scale Update Committee and American Medical Association have completely revamped the Psychiatry section of the CPT book for 2013. This is the first major update of this section since 1998. Here’s the comparison of the 1998 and 2013 updates:  

Some of the rationale behind the 2013 changes: 

• Shift from treating single disorders to managing multiple disorders and medical co-morbidities 
• Drastic reductions in inpatient beds, which have shifted site of service from inpatient to outpatient 
• More complex, higher-risk patients being seen in outpatient settings 
• Increased intensity of services due to increase in number of patient co-morbidities and complications without adequate codes

Given the high number of code changes and that they were not finalized until November, we are making every effort to map our system to accept the new codes. Please begin using the new codes January 1, 2013. To help you learn the guidelines for using the new codes, we will be offering a webinar in late January—watch for an email announcement with more details coming soon. In the meantime, you can read an overview of the code changes on the American Psychiatric Association’s website and you are welcome to contact your Provider Service Representative with any questions.

2013 Code Book Order Deadline Extended

Discounted 2013 code books are still available, and delivery is free! The order deadline has been extended to January 31, 2013. Simply complete the Code Book order form at Pacificsource.com/provider/code-book-order-form-2013.pdf and mail it with your check to:

PacificSource Health Plans
Attn: Debbie Smith, Provider Network Dept.
PO Box 7068
Springfield, OR 97475

Please note: We can only accept orders and payments for the code books at the above address. Using our Portland lock box or any other address will cause delivery delays.

Changes? A Friendly Reminder to Keep Us Informed

If your facility has recently had staffing or address changes, it’s important to let your Provider Service Representative know, so that we can continue to provide the best service possible.

• When a practitioner leaves your group, please provide the last date of employment. 
• When a practitioner joins your group, he or she will need to be credentialed with PacificSource or a PacificSource delegate (IPA). The practitioner will become effective the first of the month following approval by the PacificSource Credentialing Committee or first of the month following notification from the delegate/IPA regardless of when credentialed by the delegate/IPA.
• For an address change, please include an effective date. 
• For tax ID changes, please include the effective date for the change as well as a roster of all the practitioners that render services under the tax ID number. This way, we can be sure that all practitioners in our system are updated accordingly. 
• We also need the most current contact at the group that is responsible for credentialing practitioners. This will help ensure that practitioners don’t lose their participating status with PacificSource.

Preauthorization List Updated

We updated our commercial medical preauthorization list on January 2, 2013. Please be sure to refer to this new list rather than any older version. For more information about preauthorization, please see our Preauthorization page.

New Large Employer Clients

To give you a heads up about potential new patients—and possible coverage changes for existing patients—we provide a list of large employers that have recently enrolled with us. The number indicates total subscribers, not including dependents.

December 2012

• Crapo Farms, St. Anthony, ID – 67

January 2013 

• Montana Health Solutions, Inc., Missoula, MT – 193 
• New West Health Services, MT – 100 
• Richardson Sports, Inc., Eugene, OR – 136 
• Meadow Lark Agency, Billings, MT – 81 
• Integrated Services, Inc., Portland, OR – 64 
• Consumer Direct Management Solutions, Inc., Missoula, MT - 220
  

PacificSource Performance at a Glance - November 2012

* includes members who have medical coverage.

Questions?

Your Provider Service Representative Is Here to Help

If you have any questions, please feel free to contact your Provider Service Representative. If you are unsure who your representative is, please visit our Provider Service Staff Directory and click on your county, or feel free to email providernet@pacificsource.com.