Provider Manual—Commercial Plans

Medical Management

Updates:  Section 3.5 Retrospective Preauthorizations revised July 2019.

Quick links:

  1. Medical Necessity
  2. Case Management 
  3. Preauthorization 
    3.1 Services Requiring Preauthorization 
    3.2 Preauthorization Policy
    3.3 Sleep Disorder Treatment 
    3.4 Preauthorization Procedure 
    3.5 Retrospective Preauthorizations 
  4. Utilization Management 
    4.1 Nonreimbursed Nursing Level Charges During an Acute Care Hospital Stay   
    4.2 Concurrent Review 
    4.3 Retrospective Utilization 
  5. Quality Utilization Program 
  6. Clinical Practice Guidelines 

1 Medical Necessity

PacificSource employer contracts contain a clause specifying that services must be medically necessary to be eligible for reimbursement. “Medically Necessary” and “Medical Necessity” are terms PacificSource uses to define services and supplies required for diagnosis or treatment of illness or injury, which, in our judgment, are:

  • Consistent with the symptoms or diagnosis and treatment of the condition
  • Appropriate with regard to good medical practice
  • As likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any other service or supply, both as to the disease or injury involved and the patient’s overall health condition
  • Not for the convenience of the member, a family member, or the physician or provider
  • The least costly method of medical service that can be safely provided

A service or supply that is ordered or given by a provider does not in itself make it medically necessary.

Medical necessity determinations are not made arbitrarily. When a PacificSource claims adjudicator reviews a claim, we compare the treatment with the usual treatment provided by physicians and/or providers and hospitals to patients having similar conditions. Services are checked for correlation with the diagnosis or problem.

When the adjudicator cannot match the services with the diagnosis, or when the length of stay seems inappropriate for the diagnosis given, the claim is referred to our Health Services department. A staff of registered nurses, under the direction of the Chief Medical Officer will research and review the medical necessity. Chart notes and supporting documentation may be requested to complete the review process. If a discrepancy remains, the issue may be referred to the Medical Director or Assistant Medical Director for review. Members have the right to appeal.

2 Case Management

Complex Case Management and Case Management services are provided by PacificSource to members at no additional cost.

Members enrolled in Complex Case Management typically have extensive and intensive healthcare needs such as, but not limited to, one or more of the following:

  • Spinal cord injury/trauma
  • Eating disorders
  • Amyotrophic lateral sclerosis (ALS-Lou Gehrig’s Disease)
  • Acute or chronic conditions requiring specialized treatment programs
  • All pediatric cancer cases
  • Selected adult cancer
  • Accordant care cases with frequent ER or inpatient hospitalizations

Members enrolled in Complex Case Management engage frequently with an assigned nurse case manager who works with the member on a mutually agreed upon set of health-related goals and outcomes.

Case Management services are designed to help members who may require assistance with transfers from hospital to home, home health, home infusion, skilled nursing facility, or acute inpatient rehabilitation. They can also help with other questions related to health-related concerns, new diagnoses, finding an appropriate provider, etc.

When case management services are initiated, PacificSource will work with the patient’s physician or provider on a case-by-case basis. Case management interventions support the provider-patient relationship, identify and facilitate removal of barriers to good self-management and promote adherence to the prescribed treatment plan.

PacificSource reserves the right to delegate a third party to assist with, or perform the function of, case management. PacificSource will have final authority in all case management decisions.

Payment of benefits for supplemental services is at the sole discretion of PacificSource and may be made as a substitute for other covered benefits based on PacificSource’s evaluation of the member’s particular case. PacificSource may limit payment for supplemental services to a specific period of time.

Members may request Complex Case Management or Case Management services by contacting our Health Services department. To speak with someone regarding Case Management, please contact our Health Services department:


Oregon: (541) 684-5584, toll-free (888) 691-8209, ext. 2584
Idaho: (208) 333-1563, toll-free (800) 688-5008
Montana: (406) 442-6595, toll-free (877) 570-1563


Oregon: (541) 225-3625
Idaho: (208) 333-1597
Montana: (406) 441-3378

3 Preauthorization

Preauthorization is the process by which providers verify coverage and receive authorization from PacificSource before services or supplies are rendered. Preauthorization establishes care based on benefits available, medical necessity, appropriate treatment setting, and/or anticipated length of stay. Failure to preauthorize could result in the member unknowingly becoming responsible for payment to a provider for services or supplies not covered by this group policy. To request preauthorization, please contact the PacificSource Health Services department.

3.1 Services Requiring Preauthorization

On our website we maintain a list of procedures and services that require preauthorization. This list is subject to revision and updating as PacificSource reviews new technologies and standards of medical practice. Members on plans that require a PCP will need a preauthorization for out-of-area services that are not urgent or emergent.

Following the initial preauthorization, please notify our Health Services department in the event of the following:

  • When surgery has been rescheduled
  • When there has been a change of facility
  • When there has been a change of physician or provider

Drug Preauthorization

Please see Pharmacy section: Drug Preauthorization and Step Therapy Protocols.

Mental Health and Substance-Related and Addictive Disorders Services

Mental Health and Substance-Related and Addictive Disorders services are subject to all terms and provisions of the member’s specific health plan including limits, deductibles, co-payments and/or benefit percentages shown on the Schedule. Providers must meet the credentialing and eligibility requirements of PacificSource. Only Joint Commission accredited programs are considered to be eligible Mental Health providers by PacificSource Health Plans. Mental Health and Substance-Related and Addictive programs must be licensed by the state in which they operate as a treatment program for the particular type or level of service that is provided or organizationally distinct within a facility.

The following levels of care require preauthorization by PacificSource: inpatient, residential, partial hospitalization, and mental health intensive outpatient services. Substance abuse specific intensive outpatient does not require a preauthorization.

PacificSource expects timely notification—within 24 hours—of admissions requiring preauthorization. Admitting clinical information must be submitted within 48 hours for medical necessity determination and authorization to be completed. Lack of clinical information will result in coverage not being authorized. Initial assessment should include: Initial treatment plan, discharge plan, and estimated length of stay.

PacificSource utilizes MCG, formerly Milliman Care Guidelines’ Behavioral Health Guidelines to determine the clinical indications for admission for a primary mental health diagnoses. ASAM—American Society of Addiction Medicine (ASAM PPC-2R) is the clinical guide utilized in the assessment of appropriate levels of patient care for Substance-Related and Addictive Disorders.

Mental Health and Substance-Related and Addictive Disorders are those found in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders classification system with specific exceptions as allowed by state and federal mandates. Currently this is the DSM 5.

The facility and provider must establish, document, and communicate medical necessity for admission, continued stay, and discharge from each level of care and treatment setting. Medical necessity must be met for continued coverage authorization in the treatment setting.

Treatment which is court ordered or required by a third party must also meet medical necessity criteria and will not be approved solely on the basis of court order or third party requirement. Additionally, a therapeutic boarding school or facility that combines a structured psychosocial setting with an academic educational program does not meet medical necessity criteria for this level of care.

PacificSource believes that Mental Health and Substance-Related and Addictive Disorders Services should occur as close as possible to the home area where the patient will be discharged to help facilitate a successful transition to community based services.

Residential Treatment is defined as a 24 hour inpatient level of care that provides a range of diagnostic and therapeutic behavioral services which cannot be provided on an outpatient basis. This level of care must have four or more continuous hours of treatment per day. This treatment occurs in a facility with 7 day a week, 24-hour around-the-clock supervision on a unit that may or may not be locked depending on the specific program’s license. Treatment focus is on improving function rather than maintenance of long term gains made in an earlier program. Residential treatment and coverage is not based on a preset number of days. A standardized “program” is not considered reason for medical necessity and continued stay at this level of care. Residential treatment should occur as close as is possible to the home to which the patient will be discharged. If an out of area placement is unavoidable, there must be a family and facility commitment to assure regular family therapy and contact with the patient and the facility.

Partial Hospitalization is defined as a level of care that provides comprehensive behavioral services that are essentially the same in nature and intensity as those which would be provided in a hospital. This level is appropriate for a patient who may present with ongoing, imminent risk of harm to self or others, but is able to develop a plan to maintain safety without 24 hour psychiatric/medical and nursing care. This level of care is typically 5-8 hours per day, 5 days or less per week. This level of care is time-limited, used to stabilize acute symptoms.

Intensive Outpatient (IOP) is defined as a level of care for those patients who are not at imminent risk of harm to self or others. It is an appropriate level of care to generate new coping skills, or reinforce acquired skills that might be lost if the patient returned to a less structured outpatient setting. This level of care is generally 3-4 hours per day or less, 3-5 days per week.

Discharge Guidelines

  • Medical necessity and continued stay guidelines are no longer met, or
  • Appropriate and timely treatment is available at a less intensive level of care, or
  • Maximum program benefits have been achieved and the patient is unlikely to make further positive progress at this level of care

Discharge plans should include:

  • Coordination with family, outpatient providers, and community resources
  • Timely and appropriate aftercare appointments set prior to discharge
  • Prescription for needed medications and medications sufficient to bridge the time between discharge and follow up.

3.2 Preauthorization Policy

PacificSource Health Plans requires preauthorization of certain procedures and services to determine benefit eligibility, benefit availability, and medical necessity. Preauthorization is to establish medical necessity, this does not override our system clinical edits. Physicians and other provider offices may request preauthorization by contacting the PacificSource Health Services department. PacificSource will work with the physician or provider office to determine the following:

  • Specific type(s) of services proposed (diagnosis and procedure codes)
  • Appropriate treatment setting (inpatient or outpatient)
  • Appropriate time of admission (same day or day before)
  • Expected length of stay
  • Identification of contracted physicians, providers, and/or facilities

In some cases, PacificSource may require more information or may request a second opinion.

Prior Authorization determinations are made within two business days for nonurgent preservice requests.

Electronic Prior Authorization and Inpatient Notification Process

Effective June 1, 2019, PacificSource Health Plans strongly encourages prior authorization (PA) and inpatient notification requests to be submitted via our provider portal, InTouch. We will contact your offices to assist you in getting an account created and assist with any training. 

If you do not have access to InTouch, please visit and register. Here is a link with some more information about InTouch as well:

In some cases, your billing office may be using it already. If so, you can contact them to find out who your administrator is on the account, and they can contact OneHealthPort to have additional users added. This can include front desk personnel or anyone who needs to submit PAs.

Please do not hesitate to contact your Provider Service Representative should you have any questions. We will be happy to assist you in any training you might need to utilize this portal.

3.3 Sleep Disorder Treatment

The term “sleep disorders” includes a wide variety of conditions that can be organic such as obstructive sleep apnea (OSA) or upper airway resistance syndrome (UARS), neurological (also called “central sleep apnea”) such as narcolepsy or cataplexy, or associated with mental conditions such as insomnia due to anxiety. Mixed sleep apnea is a combination of OAS and central sleep apnea. Most sleep studies are ordered for a suspected diagnosis of sleep apnea or narcolepsy. Treatment for narcolepsy/cataplexy and insomnia is medication. Obstructive Sleep apnea and UARS may be treated medically or surgically.

Types of Sleep Studies

  • Overnight Oximetry can be done at home or in a hospital setting, and is used primarily to rule out significant sleep apnea in selected patients where the level of suspicion of the diagnosis is relatively low. There can be technical problems with unsupervised testing that can make the test difficult to interpret.
  • Nocturnal Polysomnogram (PSG) is a detailed study, usually done in a hospital setting with a technician present throughout, and includes monitoring by electroencephalography (EEG), electromyography (EMG), electro-oculography (EOG), oral and nasal airflow, chest movements, oxygen saturation, heart rate and rhythm, and measuring of snoring intensity. This test is considered to gold standard for diagnosing sleep apnea and distinguishing obstructive from nonobstructive sleep apnea.
  • Multiple Sleep Latency Tests (MSLT) measures the time it takes for the subject to fall asleep and is used primarily in cases of suspected narcolepsy.
  • Actigraphy is a method of monitoring motor activity with a portable device designed to be used while patients are sleeping. Absence of movement is consistent with sleep. Actigraphy is used either alone or with PSG to diagnose sleep disorders.
  • Home Sleep Study Testing (HST) is done using unattended portable monitoring devices. While the currently accepted method for definitive diagnosis of OSA is full polysomnography done with a qualified sleep laboratory technician in attendance, home sleep studies using unattended portable devices may be appropriate in patients with suspected OSA when an in-laboratory polysomnogram is not possible by virtue of immobility, safety, or critical illness. Home sleep studies are not considered appropriate for patients with chronic obstructive pulmonary disease or for those suspected of having other sleep complications, such as central apnea, periodic leg movement or narcolepsy.

Criteria: Sleep Studies

Some group contracts require that sleep studies be ordered by a pulmonologist, neurologist, otolaryngologist, or certified sleep medicine specialist. Sleep studies may also be ordered by family practice or internal medicine physicians (and nurse practitioners or physicians assistants working with the family or internal medicine physicians) despite not being specified in the contract language.

Preauthorization Requirements

Preauthorization is required for coverage of oral appliances for the treatment of sleep apnea. CPAP/BIPAP devices do not require prior authorization for the initial 3 month rental and convert to purchase. CPAP/BIPAP rental extension, repairs and replacement greater than $800 do require a prior authorization.

Requests for coverage of services for obstructive sleep apnea (OSA) treatment will be reviewed by the criteria below.

Coverage Guidelines: Nonsurgical Treatment of Sleep Disorders

Obstructive sleep apnea can be treated both surgically and nonsurgically.

Nonsurgical treatment options include:

  • Continuous positive airway pressure (CPAP)
  • Bilevel positive airway pressure (BiPAP)
  • Oral appliances

Criteria for Coverage of Nonsurgical Treatment of Sleep Disorders

CPAP and BIPAP includes: Auto-titrating Positive Airway Pressure (APAP) and Adaptive Servo-Ventilation (ASV).

PacificSource considers nonsurgical treatment of sleep disorders to be medically necessary when all of the following are met:

  • A PSG or HST sleep study documented AHI or RDI ≥ 10 episodes per hour of sleep OR
  • An AHI or RDI between 5 and 9 plus any of the following associated symptoms:
    • Excessive daytime sleepiness, as documented by either a score of ≥ 10 on the Epworth Sleepiness Scale or inappropriate daytime napping (e.g., during driving, conversation, or eating) or sleepiness that interferes with daily activities; OR
    • Impaired cognition OR
    • Mood disorders OR
    • Documented hypertension OR
    • Documented ischemic heart disease OR
    • Documented history of stroke

CPAP or BiPAP trial rental is covered for an initial 3 months to determine tolerance and appropriate utilization before purchase will be approved.

Conversion to purchase of CPAP or BiPAP machine is covered with receipt of the “Request for Purchase” form documenting compliance and efficacy of treatment on the follow-up visit with the specialist. This form is submitted with the claim for purchase. In the case of providers whose billing agent is not at the provider location, the form may be submitted to the Claims department separately. If continued rental (rather than purchase) of CPAP/BiPAP is desired, preauthorization through Health Services is required.

When a participating provider is not available in the members service area, services will be payable at the contracted benefit rate (Use code A36 on preauthorization request).

3.4 Preauthorization Procedure

The PacificSource Health Services department is ready to assist physicians, providers, and office staff with preauthorization services, and is available to answer questions. When all pertinent information needed to make a decision has been received, the preauthorization request will be processed according to the turnaround times established by state laws and regulations. You may reach the department in one of the following ways:


Oregon: (541) 684-5584, toll-free (888) 691-8209, ext. 2584
Idaho: (208) 333-1563, toll-free (800) 688-5008
Montana: (406) 442-6595, toll-free (877) 570-1563


Oregon: (541) 225-3625
Idaho: (208) 333-1597
Montana: (406) 441-3378


PacificSource Health Plans
Health Services Department
PO Box 7068
Springfield, OR 97475

For specific benefit information, please contact our Customer Service department by phone at (541) 684-5582 or toll-free at (888) 977-9299, or by email at Alternatively, you may call our toll-free customer service phone line especially for commercial providers at (855) 896-5208 to verify member benefits.

Preauthorization requests may be submitted as follows:

  • For MRI, CT, and PET scans, through AIM (American Imaging Management). Go online to the AIM web portal at, or submit preauthorization requests via the call center at (877) 291-0510.

Electronic Prior Authorization and Inpatient Notification Process

Effective June 1, 2019, PacificSource Health Plans strongly encourages prior authorization (PA) and inpatient notification requests to be submitted via our provider portal, InTouch. We will contact your offices to assist you in getting an account created and assist with any training. 

If you do not have access to InTouch, please visit and register. Here is a link with some more information about InTouch as well:

In some cases, your billing office may be using it already. If so, you can contact them to find out who your administrator is on the account, and they can contact OneHealthPort to have additional users added. This can include front desk personnel or anyone who needs to submit PAs.

Please do not hesitate to contact your Provider Service Representative should you have any questions. We will be happy to assist you in any training you might need to utilize this portal.

Please note, preauthorization is to establish medical necessity, this does not override our system clinical edits.

The following information is necessary to complete a request:

  • Date
  • Patient’s name
  • Date of birth
  • Member number & group number
  • CPT/HCPCS code and description
  • Durable medical equipment: rental or purchase (if applicable)
  • Date of service
  • Expected length of stay (if applicable)
  • Place of service or vendor name
  • Assistant surgeon requested (yes or no, if applicable)
  • Prior authorization determinations are made within two business days for nonurgent preservice requests
  • Diagnosis codes (ICD-10) and description
  • Ordering physician/provider and office location (first and last names please)
  • Contact person and telephone number (first and last names please)
  • Referring physician (first and last names please)

3.5 Retrospective Preauthorizations

Effective August 1, 2013, PacificSource, through its Health Services department and processes, will review clinical documentation to ensure the appropriate claims adjudication for certain services that have been provided when coverage of this service was not preauthorized as contractually required. This includes requirements defined in both the member and provider contracts.

Retrospective review determinations will be based solely on the medical information available at the time the service was provided. Results from subsequent testing or procedures cannot be considered.

All retrospective requests for authorization are completed within 30 calendar days from receipt of all necessary clinical information.

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.
  • A genetic testing request through AIM is received within 90 days of the date of service only.

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

4 Utilization Management

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.”

PacificSource Health Plans reserves the right to delegate a third party to assist with or perform the function of utilization management. PacificSource will have final authority in all utilization management decisions.

Criteria may be requested prior to a utilization management (UM) decision, or in the event of a denial, from Health Services in any of the following ways:


Call Health Services to request a copy of the criteria at the following numbers per state:

Oregon: (541) 684-5584 Toll free - (888) 691-8209, ext. 2584
Idaho: (208) 333-1563 Toll free - (800) 688-5008
Montana: (406) 442-6595 Toll free - (877) 570-1563
TTY: (800) 735-2900


PacificSource Health Plans/Health Services
110 International Way
Springfield, OR 97477



Oregon: (541) 225-3625
Idaho: (208) 333-1597
Montana: (406) 441-3378

Criteria will be provided by mail, email, or fax per your request.

4.1 Nonreimbursed Nursing Level Charges During an Acute Care Hospital Stay

Acute care hospital services are those items and services ordinarily furnished by the hospital for the care and treatment of a patient. These must be provided under the direction of a physician with privileges in an institution maintained primarily for treatment and care of patients with medical disorders. Hospital-based care is a key component of the continuum of health services. It provides necessary treatment for a disease or severe episode of illness for a short period of time. The goal is to discharge patients as soon as they are healthy and stable. Acute care hospital services and treatment provided in a hospital setting may include services such as:

  • Medical or surgical services
  • Room and board
  • Observation services
  • Nursing services
  • Nutritional Services
  • Occupational Therapy
  • Physical Therapy
  • Respiratory Therapy
  • Speech Therapy
  • Medical Social Services
  • intravenous (“IV”) injections or IV fluid administration/monitoring
  • intramuscular (“IM”) and/or subcutaneous (“SQ”) injections
  • Nasogastric tube (“NGT”) insertion, and urinary catheter insertion
  • Dressings, supplies, appliances, and equipment
  • Diagnostic or Imaging services

Services That Are not Separately Reimbursable for Participating Facilities—Nursing Procedures

PacificSource Health Plan will not separately reimburse fees associated with nursing procedures or services including leveled nursing charges provided by facility nursing staff or unlicensed facility personnel (technicians) performed during an inpatient (“IP”) admission. Examples include, but are not limited, to intravenous (“IV”) injections or IV fluid administration/monitoring, intramuscular (“IM”) injections, subcutaneous (“SQ”) injections, nasogastric tube (“NGT”) insertion, and urinary catheter insertion, venipuncture or capillary blood draws.

4.2 Concurrent Review

Concurrent review begins when a hospital receives official inpatient admission authorization (see 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 admitting during the weekend. Failure to notify health plan of admission will result in denial of service, and would be the responsibility of the provider.

Eligibility and benefits may be confirmed by contacting Customer Service and the admission should be reported to the Health Services department. Once notified, Health Services will provide a patient-specific, searchable reference number to the facility. This number is the facility’s confirmation that we have recorded the patient’s admission and that a PacificSource Nurse Case Manager will monitor and manage the patient’s hospitalization.

Our Nurse Case Managers use nationally accepted, evidence-based screening criteria, clinical experience, and standardized processes to conduct all utilization review activities, including:

  • American Society of Addiction Medicine Criteria
  • PacificSource medical criteria and guidelines
  • CMS Guidelines
  • Standard of practice in your state

Utilization review reports are requested on a case-by-case basis and, if required, PacificSource will notify the case management or utilization review department the same day that a verbal or faxed review is needed. The frequency of concurrent review will vary based on the patient’s condition, case complexity, and practice guidelines. The review process may require medical records or review with the facility Case Manager or Social Worker. We also access EMR when available.

Our nurse reviews the severity of illness and intensity of services provided during the hospital stay with the facility utilization review or case management staff to confirm need and appropriateness. Our Case Manager provides support to the member by coordinating services, equipment, or alternative placement, as indicated by the discharge plan and physician. Occasionally, the patient will wish to extend their hospitalization beyond that which the attending physician documents as medically necessary. In the case of member request, charges for hospital days and services beyond those determined to be medically necessary will be the patient’s responsibility. Only the PacificSource Medical Director or Chief Medical Officer can make decisions to not approve coverage for medical services for reasons of medical necessity.

If a determination is made that the patient no longer meets criteria for continued inpatient stay or the patient’s needs may be provided at a lower level of care (e.g., skilled nursing, palliative, or sub-acute setting), PacificSource will notify the facility and the attending physician by telephone, fax, or in writing within one to two business days. All parties are provided with notice of their appeal rights, and a 24-hour grace period may be allowed to coordinate care planning and services for patient discharge.

Charges for late discharge, outside of member’s request will not be the responsibility of the member, nor the health plan.

4.3 Retrospective Utilization

PacificSource reserves the right to retrospectively review any type of medical service. Requests for retrospective review of hospital admissions, for which we were not notified within two business days, may be reviewed at our discretion. Retrospective utilization may require review of the full medical records and may be reviewed by our Medical Director.

5 Quality Utilization Program

PacificSource’s Quality Utilization Program, administered by the Medical Director and the Health Services leadership team, provides a mechanism for systematic, coordinated, and continuous monitoring. The goal is to improve member health and the quality of services provided by the Health Services department.

6 Clinical Practice Guidelines

Clinical Practice Guidelines are recommendations for clinicians about the care of patients with specific conditions. They are based on the best available research evidence and practice experience. Guidelines are suggestions for care, not rules. However, most patients do fit guidelines and this should be reflected in overall practice patterns.

PacificSource adopts guidelines for diseases managed in the Condition Support program, relevant behavioral health conditions, preventive health guidelines for perinatal care through adults 65 years and older, as well as other guidelines relevant to the commercial population.

PacificSource adopted guidelines can be found by visiting the For Providers section of or by contacting Health Services.

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Last updated 7/2/2019