Clarification and update. See frequently asked questions below.
Effective January 1, 2024, PacificSource began completing utilization management reviews for members who have received 26 or more therapy/counseling visits. Behavioral health (BH) providers will be contacted and asked to submit clinical information.
Clinical information required will include:
- An assessment effective for the requested date range
- A treatment plan effective for the requested date range
- Progress notes, and discharge plan for specific dates of service
Any additional information that might help us understand utilization of services for this member
The purposes of these reviews are:
- To ensure treatment is medically necessary and progress is being made toward treatment objectives or goals
- To ensure adequate access for all PacificSource members
Claims may be pended if treatment documents are not received within 15 days.
Note: This policy is applicable to non-Certificate of Approval (COA) agencies/providers. Only Oregon Medicaid providers are eligible to have a COA.
For more information, please see Oregon Administrative Rule (OAR) 309-019-0100.
Frequently asked questions
Why is PacificSource initiating this requirement?
These reviews are to ensure treatments for PacificSource members are medically appropriate and necessary, and that progress is being made toward treatment goals.
Which PacificSource members will this requirement apply to?
This applies to all PacificSource members: Commercial (individual and group plans), Medicare, and Oregon Health Plan (Medicaid).
Does this requirement apply to in-network providers?
Yes.
How do I know if I'm exempt?
Only Oregon Certificate of Approval (COA) providers are exempt. For more information on licensing and certification, visit the Oregon Administrative Rules website.
How can I find out if I have a Certificate of Approval (COA)?
A COA is a specific Oregon certification for Medicaid behavioral health agencies. For more information on licensing and certification, speak to your organizational leadership or visit the Oregon Administrative Rules website.
When does the claims count start?
The claims count will start on January 1 each year, effective January 1, 2024.
Is PacificSource reviewing only behavioral health services?
No, medical necessity reviews are completed across multiple service types and not limited to behavioral health.
Is this requirement a benefit limit?
This is not a benefit limit or a stop to services. If services are medically necessary and/or appropriate, the member’s treatment will continue. If the services are not medically necessary and/or appropriate, PacificSource will work with you on next steps.
What should be included in an assessment?
Please see “Behavioral Health Outpatient Treatment” and “Documentation Requirements for Health Practitioners” policies on our Clinical policies and practice guidelines page for what should be included in assessments.
Will these reviews be random, or will providers who have seen a client for more than 26 sessions be asked to submit these documents?
The utilization reviews are not random. If a member has had 26 visits within a calendar year, the provider will receive notice to submit required documentation for review.
Does this process apply to every client in my practice and exempt further reviews?
The policy applies to all PacificSource members who have received 26 visits within calendar year. Each review does not exempt from further reviews. Please wait for PacificSource to request documentation prior to submitting.
What sessions do the reviews apply to?
The policy applies to services billed as psychotherapy sessions.
Are questionnaires required?
Questionnaires are not required. Whenever possible, it is recommended that treatment plans include objective measures, such as diagnostic screening tools, used to assess a member’s baseline function and progress during treatment. Questionnaires can be provided in addition to the required assessment, treatment, and the service notes identified on the letter requesting clinical information.
Who will be doing the review to determine whether the treatment is medically appropriate/necessary?
Licensed clinicians will complete all reviews.
What if the client previously saw a different provider? Is the review triggered at 26 sessions per client or per provider?
Reviews occur when a member has received 26 sessions per provider within a calendar year.
Can I continue to meet with my clients during the review?
Yes. There is no treatment limit on services as part of the review.
Does PacificSource need to access provider records?
PacificSource will request minimally necessary records to make determinations. This record request is covered by HIPAA under treatment, payment, and operations.
Will I need to inform new clients that they will be eligible for a total of 26 sessions (or a max of 6.5 months) only?
No. This is not a benefit limit. Members will be able to continue to access services if they are medically appropriate and necessary.
What happens if a member receives 26 sessions, then discharges and then resumes services at a later date (such as a year later) with the same provider?
These reviews will occur after 26 visits are billed during a calendar year. If a client discharges and re-initiates treatment, any documentation provided should indicate that change in episode of care, including additional treatment needs.
What do I need to include in the plan for discharge?
Clinical best practice recommends providers review treatment plans on an ongoing basis, including discharge criteria and assessed timeline for expected discharge.
What resources are available to help?
- For clinical support, contact our Utilization Management team:
Phone 888-691-8209 or email HealthServices@PacificSource.com
- For other questions, contact our Customer Service team:
Phone 888-977-9299 or email CS@PacificSource.com
- TTY: 711. We accept all relay calls.