Provider BulletinPacificSource logo

Spring 2018

In this issue:

PacificSource Partners with Treasure Valley Family YMCA's Diabetes Prevention Program >

Administrative News and Reminders >  

Medicare and Medicaid >


PacificSource Partners with Treasure Valley Family YMCA's Diabetes Prevention ProgramGettyImages-505273758_Family

The Scary Truth: According to the American Diabetes Association (The Burden of Diabetes in Idaho, pdf), in Idaho alone, approximately 10% of the adult population (more than 27,000 individuals) have diabetes, and an additional 34.9% (more than 397,000 individuals) have prediabetes. Without proper preventive measures, the Centers for Disease Control and Prevention estimate that 15–30% of the prediabetic population will develop type 2 diabetes within five years.

The Solution: We are proud to announce PacificSource has partnered with the Treasure Valley Family YMCA to engage our members in the YMCA’s Diabetes Prevention Program.

This program is available to eligible commercial members on individual or group plans, and is being offered in the Treasure Valley, Mountain Home, Twin Falls, McCall, and Baker City, Idaho areas.

For more information, see the YMCA's Diabetes Prevention Program FAQ (pdf) and brochure (pdf) for healthcare providers.


Administrative News and Reminders

"Incident to" Billing Policy Update

Effective June 1, 2018, in order for a service to be considered for payment under the “incident to” billing policy, the modifier SA must be appended to the CPT code. Only claims with the required SA modifier will be considered eligible for “incident to” billing. See the full  “incident to” billing policy.

Concurrent Review and Timely Inpatient Notification – Commercial Members

PacificSource’s Utilization Review Program, administered by the Chief Medical Officer, entails two different types of utilization review: concurrent and retrospective. We define utilization review as the “evaluation of medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities under the auspices of the applicable benefit plan.”

Concurrent review begins when a hospital receives official  inpatient admission authorization (see manual section 6.3.4  Retrospective Preauthorizations). The health plan should be notified within 24 hours (business days only), but no later than 48 hours during normal business days and the next business day if the member is admitted during the weekend. Failure to notify health plan of admission will result in denial of service, and would be the responsibility of the provider.

Retrospective requests for authorization will only be honored when:

  • The request is received within 60 days of the date of service, or
  • Within 60 days of claims notification that an authorization is required.

Requests received outside of this time frame will not be considered for retrospective review.

Montana Credentialing and Contracting Process Clarification

The application: Please make sure your supporting documentation includes: W9, copy of the face sheet for current malpractice insurance, License and DEA (when applicable). The application will be reviewed within 90 days of receipt of all information. Applications are available in the Provider sections of our websites.

Credentialing and the contract: During the credentialing process you will receive a draft contract in the mail for your review and signature. The contract will become effective after credentialing has been approved. All contracts begin on the first day of the month. 

As always, please feel free to contact us if you have questions. 

Code Books No Longer Available through PacificSource

Discounted code books will no longer be available through PacificSource effective immediately.  


Medicare and Medicaid

Claim Payment Reduction for X-Rays Taken Using Computed Radiography

CMS has reduced payments for certain imaging services as follows: X-rays taken using computed radiography (including the x-ray component of a packaged service) furnished during 2018, 2019, 2020, 2021, or 2022, that would otherwise be made under the Medicare Physician Fee Schedule (without application of subparagraph (B)(i) and before application of any other adjustment), will be reduced by 7 percent. Similarly, these x-ray services furnished during 2023 or a subsequent year will be reduced by 10 percent.

A new modifier is being established to be used on claims that describe X-ray services taken using computed radiology. Beginning January 1, 2018, hospitals and suppliers will be required to use the modifier on claims for X-rays taken using computed radiology. 

Smoking Abstinence Requirement Supports Surgery Recovery

PacificSource Community Solutions (Medicaid) follows OHA’s 01/01/2017 Prioritized List of Health Services Ancillary Guideline A4, which requires patients to quit smoking for 30 days in advance of elective surgery. For elective surgical procedures requiring prior authorization, there are two requirements when submitting an elective surgical procedure request: objective evidence of abstinence from smoking and related chart notes.

Reproductive (for example, for contraceptive purposes), cancer-related, and diagnostic procedures are excluded from this guideline. Certain other procedures, such as lung volume reduction surgery, bariatric surgery, erectile dysfunction surgery, and spinal fusion have six-month smoking abstinence requirements. 

Sample explanations for patients: 

  • American College of Surgeons:
    Smoking increases your risk of problems during and after your operation. Quitting four to six weeks before your operation, and staying smoke-free four weeks after, can decrease your rate of wound complications by 50 percent.  
  • American Association of Orthopaedic Surgeons:
    Smoking has a negative effect on fracture and wound healing after surgery. Broken bones take longer to heal in smokers because of the harmful effects of nicotine on the production of bone-forming cells.  
  • American Society of Anesthesiologists:
    After surgery, you are much more likely to need a ventilator—a machine that breathes for you—because of your increased risk of breathing and lung problems.  

For additional details, please see our flier, “Smoking Abstinence Prior to Elective Surgery.” 


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