Clarification and update. See frequently asked questions below.
Effective January 1, 2024, PacificSource will begin 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, which will be reviewed for ongoing service.
Clinical information required will include:
- Most recent assessment
- Current treatment/service plan
- Five most recent treatment/service notes
The purposes of these reviews are:
- To ensure treatment is medically necessary and progress is being made toward treatment objectives/goals.
- To ensure adequate access for all PacificSource members.
Claims may be pended if treatment documents are not received within 30 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.
Does this requirement align with Medicare and the Centers for Medicare & Medicaid Services (CMS) as Traditional Medicare expands access to behavioral health provider types in 2024?
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, 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 12 months, 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 12 months.
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.
Are the 26 sessions per year, or do they accumulate forever?
The policy applies to members who have received 26 visits within 12 months.
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 12-month period.
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? Are they considered a “new client,” or do utilization management reviews go into effect immediately as the client already has a prior history of 26 sessions with that provider?
These reviews apply to all members who have received 26 visits within 12 months. Members who re-engage in care, and who do not reach the 26 visits within a 12-month period, will not meet this review’s criteria.
What resources are available to help?
-
Support for providers – Connect with your Provider Service Representative for additional information. Visit the Provider Service Representative Directory for your local representative.
- Support for members – PacificSource has Care Managers and member support staff who can help members connect to care. Contact our Customer Service team at CS@PacificSource.com or 888-977-9299, TTY: 711. We accept all relay calls.