Provider Bulletin - Winter 2017

In this issue:

General News and Information

Urgent vs. Emergent Preauthorization Requests >

PacificSource Policy on Retroactive Rate Adjustment >

Quality Corner >


Commercial News

Telehealth Service Guidelines >  


Medicaid and Medicare News

Enrollee Rights Reminder >

Central Oregon Resources for Diabetes Prevention >

Medicaid Benefits That May Surprise You >  

New Workgroup Aims to Improve Hypertension Control >


General News and Information

Urgent vs. Emergent Preauthorization Requests

2016-04 Winter: Emergent

As a reminder, please be careful when indicating whether or not a preauthorization request is urgent or emergent. We have seen an unusually large increase in requests marked urgent that do not fit the definition and guidelines for such. Please see PacificSource definitions below.

Urgently Needed Care: Care provided to treat a nonemergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed care may be furnished by in-network providers or by out-of-network providers when in-network providers are temporarily unavailable or inaccessible.

Non-emergent Condition: Routine medical care, such as diagnostic work-ups for chronic conditions, elective surgery, and scheduled follow up visits for prior emergency conditions.

Please contact your Provider Service Representative if you have any questions.

PacificSource Policy on Retroactive Rate Adjustment

2016-04 Winter: RetroactivePacificSource loads fee schedules into our claim system from a variety of external sources, including CMS, DMAP, Optum, ASA, Noridian, and FairHealth. These published or submitted reimbursement rates are made available to PacificSource via publications or downloads and supplied directly by providers and facilities.

In cases where the source of retroactive effective dates is external, including websites and provider submissions of Noridian rate sheets, PacificSource will not reprocess claims to accommodate the adjustments. An exception to this policy would be if specific direction on retroactive adjustments comes directly from a regulatory or governmental agency.

Occasionally, retroactive rate adjustments may be the result of our oversight, delay, or error. In these cases, we will reprocess affected claims when the difference between the previous total claim allowable and the corrected claim allowable is greater than $10 for non-IPA providers, and $25 for IPA providers. Adjustment will be made either as an additional payment or as a refund request. Appropriate reporting to necessary governmental agencies on reprocessing claims based on member impact will still apply.

Quality Corner

PacificSource participates in a number of quality measurement programs on an annual basis. If medical records are required, our vendor, Optum Solutions, or a PacificSource staff member will contact you to arrange for convenient collection of that information. Optum uses two vendors to assist with the retrieval. Please be assured our members’ personal health information is maintained in accordance with all federal and state laws.

For more information about these initiatives, please see the Spring 2016 issue of our newsletter.

Below is the timeline and vendor for each project. We thank you in advance for your partnership with these important quality improvement initiatives. If you have questions, feel free to contact Sabrina Stuart at (800) 624-6052, ext. 3619.

Quality Program







Medicare Risk Adjustment July January ECS
Commercial Risk Adjustment September March ECS
Healthcare Effectiveness Data and Information Set (HEDIS) - Medicare and Commercial February Mid-May ArroHealth

Commercial News

Telehealth Services Guidelines 

2016-04 Winter: Telehealth

Tele-video medicine, also known as telehealth, is a newer concept, but very much needed—especially in rural areas. 

Some services for telehealth can be payable depending on the member’s benefit plan. To be eligible for payment, services must be provided via audio-video or other telecommunications technology over a secure connection that complies with HIPAA privacy regulations. Telemedicine via audio only, telephone only, email, or fax transmission is not covered.

Preauthorization to use tele-video medicine service is only required if it would be required for the in-person service.

Tele-video medicine communication services are subject to all terms and conditions of the member’s plan, including applicable deductible, copayment, or coinsurance. In general, the member’s cost share is the same as it would be if the service had been provided in person. Services can be subject to retrospective review for medical necessity.

Services must also meet several standards to qualify for coverage under the health plan:

  • Eligible tele-video services are limited to two-way real time video communication (does not apply to telephone or other electronic transmission of data). Skype and Facetime are not coverable. 
  • Services must be medically necessary and eligible for coverage if the same service were provided in person. 
  • Providers must be eligible for reimbursement under the PacificSource health contract. 
  • Modifier GT (Via interactive audio and video telecommunications systems) must be appended to the CPT or HCPCS code unless video communication is integral to the code (e.g., 0188T does not require a GT modifier). 
  • Facility fee charges for the originating site are ineligible for reimbursement. 
  • Eligible originating sites include but are not limited to: hospitals, health clinics, physician’s offices, community mental health centers, skilled nursing facilities, and renal dialysis centers. 
  • Telephone visits/audio only are not covered. 
  • Email, fax, and e-visits are not covered. 

Additional resources:

MT State Law Telemedicine/Telehealth Definition

American Telemedicine Assn. Guidelines

HIPAA Guidelines on Telemedicine

CMS Telehealth Services (PDF)


Enrollee Rights Reminder

2016-04 Winter: RightsAs a contracted PacificSource provider, please be aware of Medicaid Enrollee Rights and your responsibilities to comply with these rights. These rights and responsibilities are outlined in the Provider Manual (section 9.4), which was recently updated.

You can access the manual from our website,, or by following this direct link to the posted PDF.

Central Oregon Resources for Diabetes Prevention

Health Agencies, Clinics, and Community Partners Focus on Prediabetes and Diabetes Prevention in Central Oregon

Are your patients at risk for type 2 diabetes?

  • Test them today for prediabetes.
  • Recommend the Prevent T2: Diabetes Prevention Program for those at risk.

One in three American adults is at risk for developing diabetes, and most of them don’t know it. An estimated 1.1 million Oregon adults (37%) have prediabetes, which puts them at high risk for developing type 2 diabetes. If current trends continue, the number of Americans with diabetes in 2050 could be one in three. It is critical for us to change the course of type 2 diabetes with evidence-based approaches—both within the healthcare system and through community-based resources. Here are two valuable resources we recommend.

Prevent T2 Diabetes Prevention Program 
This free, 12-month program is proven to help people with prediabetes make achievable and realistic changes and cut their risk of developing type 2 diabetes. The group setting with trained lifestyle coaches provides a supportive environment with people who are facing similar challenges and trying to make the same changes. Participants meet weekly for the first six months, then once or twice a month for the second six months. 

Prevent T2 is now being offered throughout Central Oregon in Redmond, Prineville, Madras, La Pine, and Bend. New workshops are planned for Redmond, Bend, and La Pine in early 2017, with more to follow throughout Central Oregon.
To learn more about the research findings, how the program is funded, and more, feel free to contact Sarah Worthington, (541) 322-7446, at Deschutes County Health Services or visit

Regional Health Improvement Plan Diabetes Clinical Workgroup 
The Regional Health Improvement Plan (RHIP) Diabetes Workgroup is comprised of representatives from healthcare providers and clinical settings throughout the tri-county region. This group has been convened by the Central Oregon Health Council to support efforts that bring about improvements in health indicators outlined in the Diabetes Section of the RHIP. View the PDF.

The RHIP workgroup has developed a workflow that can act as a reference for any clinical setting to use for adult patients or clients with prediabetes. This workflow illustrates the processes from screening to counseling, referral, and follow-up.

In conjunction with this project, one of our members is presenting to the St. Charles Grand Rounds on March 3, 2017, on the subject of prediabetes ("Preventing a Chronic Disease by Management of Prediabetes").

Medicaid Benefits That May Surprise You

2016-04 Winter: Quality

Oregon Health Plan members have access to a wide array of benefits. Recent changes to Oregon’s Medicaid plan have expanded those benefits to cover even more services. Here are some of the services that are now covered:

  • Dental benefits for adults age 21 and older
    • Basic dental care that covers exams, teeth cleaning, fluoride, fillings, and tooth removal, and more.
  • Transportation for nonemergency medical appointments if member has no other means of transportation.

Contact information for rides:

Central Oregon CCO members
Cascades East Ride Center
(541) 385-8680 or (866) 385-8680

Columbia Gorge CCO members
Mid-Columbia Council of Governments
(877) 875-4657

  • Mental health benefits, including outpatient behavioral health (BH) and Applied Behavioral Analysis (ABA), a treatment for young people with Autism Spectrum Disorder, was transferred from OHA to PacificSource. 

New Workgroup Aims to Improve Hypertension Control

Central Oregon has a new Clinical Cardiovascular Disease (CVD) workgroup. This group was formed to address the clinical goal of the Regional Health Improvement Plan (RHIP): improve hypertension control.

To date, this group has developed three patient-facing documents to support providers and clinics in addressing hypertension. The first document is a poster that can be placed on an exam room wall that explains the way to properly take blood pressure. The second shares keys things that potentially raise someone’s blood pressure.

The final document discusses the benefits of quitting tobacco and where to get additional help within Central Oregon. These materials are currently being translated in Spanish. All of these documents can be found under the Clinical CVD workgroup section of the RHIP workgroup’s webpage:

If you are interested in participating in this workgroup or any other RHIP workgroup, please connect with us at:

Contact Us


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PacificSource Community Health Plans is an HMO/PPO plan with a Medicare contract.