We would like to inform you of changes to utilization management prior authorization submission requirements for PacificSource Community Solutions (Medicaid).
Effective April 14, 2025, procedures, treatments, and devices that do not require prior authorization will not be reviewed for medical necessity, and a cancelation notification will be provided. These services will remain subject to benefit availability, eligibility requirements, and the claims clinical editing process.
Services that do not require prior approval include:
- Procedures found on the Diagnostic Procedure Codes List
- Codes listed as “No PA Required” on the PacificSource Prior Authorization Grid
Retroactive requests must be submitted before billing the plan for payment. PacificSource will cancel any retroactive requests that have been billed prior to receiving approval. For reconsideration of a denied claim, you may submit an appeal.
For determination of coverage, please see the resources on the Line Finder page or contact Customer Service at 800-624-6052, TTY: 711. We accept all relay calls.
Additionally, services not requiring preapproval must be provided by an in-network provider, and the member must be eligible at time of service.
Notification of all inpatient admissions must still be made to PacificSource within two (2) business days from the date of service. Concurrent review will be performed as described in the Provider Manual.
Questions?
If you have any questions regarding the cancelation of your requests, or if you’d like your request to be reviewed even though authorization is not required, please contact the PacificSource Medicaid Utilization Management team.
You can send us a secure message through the Provider InTouch Portal anytime, or call us Monday through Friday, 8 a.m. to 5 p.m., at 541-330-7301.
For further questions regarding these changes, please contact your PacificSource Provider Service Representative.