News and updates
Humira coverage is changing for Medicaid members
Here’s what you need to know:
Coverage of Humira (adalimumab) through PacificSource Community Solutions will change to other, biosimilar formulations.
Will I still be able to prescribe Humira?...
Stay extensions available for members in skilled nursing facilities (Medicaid)
PacificSource Community Solutions (Medicaid) allows a 20-day skilled nursing facility (SNF) stay for individuals who qualify for skilled care. Prior authorization is not required for admission to a...
Behavioral Health treatment plans required in 2024
Effective January 1, 2024, PacificSource will begin completing utilization management reviews for members who have received 26 or more therapy/counseling...
Trigger finger or thumb surgical procedure will require prior authorization effective November 1, 2023
For Medicaid plans: Effective November 1, 2023, a prior authorization will be required for CPT Code 26055 (Tendon Sheath Incision).
Pharmacy Coverage Updates Effective September 15, 2023
We would like to inform you of changes to our PacificSource Community Solutions formulary and coverage policies....
Medicaid Grievance and Appeals policies updated
These updated documents contain policy guidance for the Medicaid Grievance and Appeals System. The changes will also be included in the next update of our Provider Manual. ...
End of the COVID-19 Public Health Emergency FAQ
The COVID-19 National Emergency and PHE ended on May 11, 2023. Our FAQ provides a brief overview of changes for Medicare and Medicaid providers.
The FAQ includes:
Answers to general questions
An...
Prior authorization changes for July 2023
Effective July 3, 2023, PacificSource will require prior authorization codes 74740 (hysterosalpingography, radiological supervision and interpretation),...
Imaging and genetic testing review timelines change
As of March 24, 2023, Carelon Medical Benefits Management (formerly AIM Specialty Health) will review prospective and retroactive authorizations up to 60 calendar days from the date of...
What you need to know about Medicaid renewal
After a three-year pause, the process of checking member eligibility for renewing Medicaid health insurance coverage has begun again. It’s estimated that anywhere between 5 and 15 million people are...