Latest Notices and Updates

If you have questions about any of the information on this page, you're welcome to contact us.

  • Idaho/Montana (800) 624-6052 ext 1459 7:00 a.m. – 5:00 p.m. MT
  • Oregon/Washington (800) 624-6052 ext 1457 7:00 a.m. – 5:00 p.m. PT

For claims questions, member benefits, and eligibility information, please contact our Customer Service team at (888) 977-9299. For provider issues, please contact your Provider Service Representative or call (855) 896-5208.

Effective August 16, 2020, the 835 PLB Segment Will Include the Patient Account Number 

If you are currently enrolled to receive Electronic Remittance Advice (835), this enhancement will result in additional data you receive via 835 transaction on corrected claims. 

The following is an example of the update:

CAS*CO*45*39.84~ REF*6R*54321~ AMT*B6*209.16~ LQ*HE*N381~ PLB*1902J27772*20201T31*WO:11113944X000 10799X7420*216.25~ SE*70*0002~ GE*2*3490~ IEA*1*000059014~

Beginning August 16, 2020, the 835 Provider-Level Balance (PLB) segment sent on an adjustment will have the provider's patient account number added to the 835 PLB segment. This enhancement will enable providers to track and post to the patient more easily. No existing data will be removed or changed. The only change is that we have added this additional field containing patient account number to the existing 835 PLB segment. 

If you are not currently enrolled to receive 835 ERAs and are interested in doing so, please fill out the ERA and EFT Authorization Agreement.

Please reach out to your Provider Service Representative with any questions you may have.

Drug List Change Notifications Posted For August

The notification contains changes for the Preferred and state-based lists, as well as our medical utilization management criteria (preauthorization, step therapy criteria). See the August 2020 Drug List Change Notification for changes effective August 22, 2020.

Change to MME Limit

Updated June 17, 2020. The Centers for Disease Control, Oregon Health Authority, and the Centers for Medicare and Medicaid Services have lowered their recommended daily Morphine Milligrams Equivalents (MME). In light of these new recommendations, PacificSource will initiate a limit of an accumulative 300 MME on December 16th, 2019, with continued titration to 90 MME. See our Opioid FAQ for Commercial Providers for details, including the effective date timeline.

COVID-19 FAQ for Providers: Reimbursement, Telehealth, and More

In our effort to support providers, we've compiled COVID-19-related answers to the most commonly asked questions about coding instructions, reimbursement provisions, telehealth, and more. We want to help.  Download the FAQ (pdf), updated June 3.

COVID-19 Provider Relief Plan FAQ

See our FAQ,  COVID-19 Provider Relief Plan and Other Frequently Asked Questions (pdf), for answers to questions we’ve received from our provider community in response to the COVID-19 Provider Relief Plan. The Provider Relief Plan supports contracted providers in this time of crisis and reduces administrative and financial burdens. This FAQ will be updated as additional information is available. 

Note: The Emergency Temporary credentialing application is ONLY relevant to providers and or groups who have an active contract in place. 

Updates to AIM Advanced Imaging Clinical Appropriateness Guidelines

Effective for dates of service on and after August 16, 2020, the following updates will apply to the AIM Advanced Imaging of the Chest and AIM Oncologic Imaging Clinical Appropriateness Guidelines. 

Advanced Imaging of the Chest updates by section:

Tumor or neoplasm

  • Allowed follow-up of nodules less than 6 mm in size seen on incomplete thoracic CT, in alignment with follow-up recommendations for nodules of the same size seen on complete thoracic CT
  • Added new criteria for which follow-up is indicated for mediastinal and hilar lymphadenopathy
  • Separated mediastinal/hilar mass from lymphadenopathy, which now has its own entry

Parenchymal lung disease – not otherwise specified

  • Removed, as it is covered elsewhere in the document (parenchymal disease under Occupational Lung Diseases and pleural disease under Other Thoracic Mass Lesions)

Interstitial lung disease (ILD), nonoccupational, including  idiopathic pulmonary fibrosis (IPF)

  • Defined criteria warranting advanced imaging for both diagnosis and management

Occupational lung disease (adult only)

  • Moved parenchymal component of asbestosis into this indication
  • Added berylliosis

Chest wall and diaphragmatic conditions

  • Removed screening indication for implant rupture due to lack of evidence indicating that outcomes are improved
  • Limited evaluation of clinically suspected rupture to patients with silicone implants

Oncologic Imaging updates by section:

MRI breast

  • New indication for BIA-ALCL 
  • New indication for pathologic nipple discharge 
  • Further define the population of patients most likely to benefit from preoperative MRI 

Breast cancer screening

  • Added new high-risk genetic mutations appropriate for annual breast MRI screening

Lung cancer screening

  • Added asbestos-related lung disease as a risk factor

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines at aimspecialtyhealth.com/resources/clinical-guidelines.

Letter to Providers: Provider Relief Plan

Read the March 27, 2020, letter to providers (pdf) from PacificSource President and CEO Ken Provencher regarding our relief plan for providers. 

COVID-19 Action Plan and Coding Guidance

As PacficSource monitors the spread of the coronavirus (COVID-19), our aim is to keep you informed while applying provisions to help curtail the outbreak and optimize access to care.

Although the severity and impact of the coronavirus outbreak is difficult to predict, we remain in close contact with healthcare providers, state coronavirus response teams, and health agencies in preparation to respond to the needs of members, employees, and providers. 

No member out-of-pocket costs
For the next 60 days per the state-of-emergency declarations, PacificSource is waiving member out-of-pocket costs for COVID-19 testing- and diagnosis-related visits (regardless of the place of service, including telemedicine). 

PacificSource is also covering a one-time early-refill for prescription drugs.
 
Coding guidance for COVID-19
The CDC has released Official Coding Guidance for reporting healthcare encounters related to the 2019 novel coronavirus (COVID-19):

 

Condition

ICD-10 Diagnosis Codes

Pneumonia, confirmed as due to COVID-19

J12.89, B97.29

Acute bronchitis, confirmed as due to COVID-19

J20.8, B97.29

Bronchitis NOS, confirmed as due to COVID-19

J40, B97.29

Acute/lower respiratory infection NOS, confirmed as due to COVID-19

J22, B97.29

Respiratory infection NOS, confirmed as due to COVID-19

J98.8, B97.29

Acute respiratory distress syndrome, confirmed as due to COVID-19

J80, B97.29

Possible exposure to COVID-19, condition ruled-out

Z03.818

Exposure to confirmed COVID-19

Z20.828

 

Coders should follow the Official ICD-10 guidelines for guidance on sequencing, reporting signs and symptoms, and reporting conditions stated as "suspected," "possible," or "probable."

We recommend providing immediate training to your clinicians regarding proper documentation related to COVID-19. We also recommend providing immediate training to your coders regarding proper ICD-10 assignment for encounters related to COVID-19.

The complete CDC update is available for download here.  

The Annual Healthcare Survey is Coming!

It’s that time again: The annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) is underway.  

Participants are chosen at random, so it’s possible some of your patients could be selected. We’ve been letting members know to be on the lookout for the survey, which is overseen by a company called SPH Analytics.

If asked, feel free to let clients know that a healthcare survey from SPH Analytics is legitimate, and that their personal information will not be shared

Thanks for your assistance, and for helping us make healthcare better.   

Learn about the survey on our blog. >>

Use Our Easy Prior Authorization Search Page

As a reminder, clinical criteria are subject to change at any time throughout the year. Please use our online Prior Authorization Grid search page to find which codes require prior authorization.

Change in Provider Contract Effective Dates

We have some great news!  Effective January 1, 2020, once a provider has been approved through the credentialing process, practitioners and facilities will be effective on the:

  • PacificSource Commercial: Date of approval by the Credentialing Committee, as long as the contract is in effect at the time of credentialing approval. 
  • PacificSource Medicare: Date of approval by the Credentialing Committee, as long as the contract is in effect at the time of credentialing approval and Medicare participation is verified.  If Medicare participation is not able to be verified immediately following credentialing, the provider will be added as participating effective on the date of Medicare eligibility. 
  • PacificSource Community Solutions: Date of approval by the Credentialing Committee, as long as the contract is in effect at the time of credentialing approval and Medicaid participation is verified.  If the Medicaid participation date is after credentialing approval, the provider will be added as participating with the Medicaid participation approval date.

Please contact your Provider Service Representative should you have any questions or need further clarification.

New Consolidated Explanation of Benefits

We’ve updated our EOB statements. Instead of receiving a separate EOB for every claim, our members will start receiving a consolidated EOB that combines their claims from a 3-week period. These consolidated EOBs and the original single-claim EOBs will both be available for members to view on our online member portal, InTouch

Home Health Prior Authorization Requirement Changes Effective January 1, 2020 

Good News for providers and members!  Effective January 1, 2020, PacificSource will no longer require a prior authorization for home health.  This includes home health:

  • Nursing
  • Social worker
  • Physical therapy 
  • Occupational therapy
  • Speech therapy services

Newborn Hearing Screening

In alignment with CMS, effective immediately CPT code 92586 when reported with a facility POS will be included in the payment to the facility only. CPT code 92586 reported by a provider on a professional claim with a facility POS locations 21 and 22 will be denied. Services performed in the office as part of a routine well child exam will remain payable. If you have any questions, please contact your Provider Service Representative.

Change to Billing Requirements, Office Surgery Suites and Fees

Change effective October 1, 2019: When billed in an office place of service, PacificSource Health Plans will not reimburse any service appended with modifier SU or FF—the costs associated with operating an office, using the facility, and using the equipment for any procedure. See Billing Requirements, Office Surgery Suites and Fees.

Genetic Testing Program Launch 

We have entered a new era of precision medicine, where treatments can be targeted and disease risks identified for individuals based on their unique genetic makeup. Today, there are thousands of genetic tests available, and the number is growing. Navigating this rapidly advancing area of medicine can be a challenge for your practice and your patients.

PacificSource is pleased to announce a new genetic testing program beginning July 1, 2019. (Prior authorization for genetic testing recently changed as well.) PacificSource has partnered with AIM Specialty Health® (AIM) to help ensure quality care while reducing costs associated with testing that is not evidence-based. In collaboration with you, our valued providers, our genetic testing program will ensure our members have access to appropriate testing. 

Learn more in our Genetic Testing Program FAQ (PDF).




InTouch for Providers

Access your PacificSource account information 24/7.

Medicaid Dental Providers

Learn more about our contracted dental provider networks for Medicaid dental services.

Learn more >

Dental Providers: Join Advantage Dental Today

Advantage Dental is the exclusive network for PacificSource Health Plans, and we’re growing throughout the Northwest. As a participating provider, you’ll enjoy the benefit of increased patient access. The contracting process is easy, and there are no fees to participate! 

To get started, go to Credentialing.AdvantageDental.com.

Your Provider Service Representative

Your PacificSource Provider Service Representative is available any time you have a question or concern. If you're not sure who your representative is, please visit our Provider Service Staff Directory.

Last updated 6/23/2020