Latest Notices and Updates

If you have questions about any of the information on this page, you're welcome to contact us. For claim questions, as well as member benefits and eligibility information, please contact our Customer Service team at (888) 977-9299. For provider issues, please contact your Provider Service Representative or call (855) 896-5208. 

2019 Formulary Changes

This notification is to inform you of changes to our medical drug formulary for all PacificSource Medicare, Medicaid, and Commercial Plans. Effective January 1, 2019, the following changes apply:

Prior authorization will be required for the following medical codes 

Medical Drug Alternative

Prescription Drug Alternative

J1453
Emend (fosaprepitant) injection

Granisetron injection (J1626)

Ondansetron HCl Tablet 4 MG Oral

Ondansetron HCl Tablet 8 MG Oral

Ondansetron HCl Tablet 24 MG Oral (quantity limit may apply)

J2469 
Aloxi (palonosetron hydrochloride) injection

C9463
Aprepitant injection (Cinvanti)

C9464
Rolapitant (Varubi)

J9315
Romidepsin (Istodax)

J7504
Antihymocyte Globulin Equine (Atgam)

J1575
Immune globulin/hyaluronidase, (Hyqvia)

J9328
Temozolomide injection


Your action may be required:

  • Patients currently prescribed medications listed on the 2019 Formulary Changes may require new prescriptions for alternative medications. Note that some medications may not have alternatives. Please discuss the necessity of continuing prescribed medications with these patients.
  • If you feel it is medically necessary for a patient to continue a particular medication, please request a prior authorization. To request a prior authorization, submit pertinent documentation via the InTouch portal on our website or speak to a Pharmacy Services representative at one of these phone numbers: 
    • Pharmacy Services Commercial (844) 877-4803
    • Pharmacy Government Services (888) 437-7728

Remember: Oregon Prescription Drug Monitoring Program (PDMP) Now in Effect

As you may already know, Oregon House Bill 4143 requires all Oregon providers to register in the Prescription Drug Monitoring Program. Read more in our Provider Bulletin .

Subscribe to our Provider Bulletin e-newsletter! You can subscribe or unsubscribe at any time.   We value your privacy

New Medical Record Signature and Date Requirements

We are adopting the CMS signature requirements across all lines of business, to ensure that services have been accurately and fully documented, reviewed, and authenticated. All medical records, chart notes, procedures, and orders submitted for review must be signed and dated by the rendering practitioner.

  • A medical record that does not contain a valid signature may result in claim denials or recovery of overpayments.
  • Signatures added to documentation following a claim denial will not be accepted.

Handwritten and digital signatures

Handwritten signatures must appear on each entry, be legible, at least include the practitioner’s first initial and last name, and include the practitioner’s credentials (PA, DO, MD, etc.).

If using digitized or electronic signatures, the responsibility/authorship of the signature should be clearly defined. These signatures require a minimum of a date stamp (preferably with a time notation), a printed statement such as, “Electronically signed by,” followed by the practitioner’s name and credentials.

Restrictions

PacificSource may request a signature log with any review of medical records to verify a provider’s signature or initials.

Unacceptable signatures include signature stamps, missing signature on dictated and/or transcribed documentation, "signed but not read" notations, and illegible lines or marks.

Exceptions

PacificSource will permit the use of an attestation form when a signature or date has been inadvertently omitted. Late entries, addendums, or corrections to a medical record should bear the current date of that entry and should be signed by the person making the change.

For more information, please refer to section 4.4.1 of the Provider Manual.

HEDIS Spotlight: Breast Cancer Screening 2018

Breast Cancer Screening:
Breast Cancer Screening is a HEDIS-preventive measure, and included in the overall STAR rating for Medicare.

Who is included:
Women between 52 and 74 years of age who have had one or more mammograms on or between October 1, 2016, and December 31, 2018.

Who is excluded:
Patients with a bilateral mastectomy any time during the patient’s history through December 31 of the measurement year. For patients who have had a bilateral mastectomy, you can bill ICD-10CM Z90.13; this helps ensure that patients are appropriately excluded from the measure while also helping to utilize resources to address gaps in breast cancer screening among your patient population.

Importance of screening:
In the U.S. for 2018, the American Cancer Society estimates:
  • 266,120 new cases of invasive breast cancer
  • 63,960 new cases of carcinoma in situ (CIS) (CIS is non-invasive and the earliest form of breast cancer)
  • 40,920 deaths from breast cancer
Tips for improvement:
  • Document and apply appropriate codes for women with a history of a mastectomy.
  • Educate and encourage all women within the age group on the importance of preventive screening and early detection.
  • Create a system to initiate reminders for women who are due for routine screening.
  • Identify any barriers that may be preventing your patient from getting their preventive screening completed.

Free One-hour Training Module with CMEs

Topic: "Changing the Conversation About Pain: Pain is Everyone's Job"
Lisa Millet, Oregon Health Authority (OHA) Public Health Injury and Violence Prevention

The OHA Public Health Division’s Injury and Violence Prevention Section has partnered with the Oregon Pain Management Commission to share a one-hour free training module with continuing medical education units for healthcare professionals. Information in this training can transform our understanding of pain and help us in our efforts to reduce unnecessary use of opioids among patients with persistent pain. OHA is also developing a public health education campaign that will include basic concepts of this training and will be launched in 2019.

Module link: http://www.oregonpainmodule.org/course01/

Contact: Lisa Millet, Injury and Violence Prevention Manager, lisa.m.millet@state.or.us

Support for New Mothers in the Central Oregon Area

"Life After Birth" is a free post-partum support group hosted by St. Charles Center for Women's Health in Redmond, Oregon. The group is open to all new mothers, regardless of where they receive care. For more information and to register, see the Life After Birth page.

Retrospective Preauthorization Update

The Medical Management section of the Provider Manual was recently updated. Retrospective Preauthorization has been updated as follows:

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.

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

"Incident to" Billing Policy Update

Effective June 1, 2018, in order for a service to be considered for payment under the “incident to” billing policy, the modifier SA must be appended to the CPT code. Only claims with the required SA modifier will be considered eligible for “incident to” billing. See the full  “incident to” billing policy.

PacificSource Partners with Treasure Valley Family YMCA's Diabetes Prevention Program

The Scary Truth: According to the American Diabetes Association (The Burden of Diabetes in Idaho, pdf), in Idaho alone, approximately 10 percent of the adult population (more than 27,000 individuals) have diabetes, and an additional 34.9 percent (more than 397,000 individuals) have prediabetes. Without proper preventive measures, the Centers for Disease Control and Prevention estimate that 15–30 percent of the prediabetic population will develop type 2 diabetes within five years. 

The Solution: We are proud to announce PacificSource has partnered with the Treasure Valley Family YMCA to engage our members in the YMCA’s Diabetes Prevention Program. This program is available to eligible commercial members on individual or group plans, and is being offered in the Treasure Valley, Mountain Home, Twin Falls, McCall, and Baker City, Idaho areas. For more information, see the YMCA's Diabetes Prevention Program FAQ and brochure for healthcare providers. 

Learn About an Opioid Alternative for Your Low-Back-Pain Patients 

Free class for healthcare providers: Exercise Therapy as Opioid Alternative for LBP: Tools for Physicians 

Join Colin Hoobler, PT, DPT, MS, and a team of contributing physicians as they demonstrate how to practically apply science to exercise—such as biomechanics, anatomy, and neuroscience—to treat patients (including those who are opioid addicted) with chronic, mechanical low back pain (MLBP). The class will focus on how to combine clinical rehabilitation principles with medical research to yield practical clinical skills. 

Date: Saturday, April 21, 2018, noon to 2:00 p.m. (PT)

Location: Boss Sports Performance, 1305 SE Armour Rd #110, Bend, OR 97702      Map

Click here to register

Class size is limited to 25 participants. The Central Oregon Health Council’s Pain Standards Task Force is the primary sponsor for this event. Course textbooks on exercise prescriptions will be provided. All proceeds will go through a local 501(c)(3), Preventive Health Awareness, and profits will be donated to KIDS Center.

This class has been reviewed and is acceptable for up to 2.00 Prescribed credits by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the class.

Time-based Codes 

To ensure timely payment of claims, please remember to provide documentation of start and end times when billing for time-based codes. Claims that come in without this documentation will be denied. 

Provider Survey on our 2017 Tobacco Cessation Campaign

Last November, as part of our annual tobacco cessation campaign, we created a flier and video for healthcare providers. We’d like your feedback on these materials as well as on our tobacco cessation program, Quit for Life. 

The survey has 7 questions and should only take about 5 minutes to complete. 

Thank you for your time and valuable input. Your responses will help us improve our tobacco cessation outreach efforts in the future. 

Click here to take the survey >

Office Service Claims

August 23 Update

PacificSource had previously changed its Provider-based Billing Policy (see original notice below) regarding office services. Now, we allow these claims with dates of service on or after August 1, 2017. Thank you for your patience and cooperation. If you have any questions about this change, you're welcome to contact your Provider Service Representative or our Provider Services team:

Email: providerservicerep@pacificsource.com 
Idaho and Montana: (541) 246-1459 
Oregon: (541) 246-1457 

Original Notice

Please be aware, all office services submitted with dates of service on or after May 1, 2017, must be billed under the service provider, in an ANSI 837P format (CMS 1500), and with the “office” place of service (POS).

Effective May 1, 2017, PacificSource will no longer accept provider-based billing of office services, regardless of the office location. We will deny as noncovered any office services billed on a UB claim form, and you will need to resubmit them in the correct format.

Claims in the following formats are not reimbursable: 

  • Claims billed with revenue codes 051X
  • Evaluation and Management codes (CPT 99201-99215 and HCPC G0463) that are billed with revenue codes 0760 through 0769
  • Claims with a “PO” modifier

Thank you for your cooperation. If you have any questions about this change, you’re welcome to contact your Provider Service Representative or our Provider Services Department:

Email: providerservicerep@pacificsource.com
Idaho and Montana: (541) 246-1459
Oregon: (541) 246-1457 

Changes to Drug Testing Policy for Commercial Plans

June 2017 - Recent changes to our urine drug testing policy may affect your patients with PacificSource commercial coverage. This change does not apply to PacificSource Community Solutions (Medicaid) or PacificSource Community Health Plans (Medicare) coverage. Read the full notice:  Changes to drug testing policy (PDF).  

Change to Chart Retrieval Calls

As you may know, PacificSource is currently retrieving charts for the 2017 HEDIS submission. The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool health plans use to measure things like care and service. ArroHealth may have contacted you to request a chart retrieval. 

New vendor
We will also work with CiOX Health, which will assist ArroHealth to collect remaining charts.

What to expect
In the coming days, a CiOX Health representative may contact you. They will walk you through how to send your charts to them, whether it is by mail, fax, remote, or on-site retrieval. It’s okay if you already sent your charts to ArroHealth. ArroHealth will manage your charts, and it will be as if there was no change in chart retrieval vendor. If CiOX contacts you, and you already sent your charts to ArroHealth, simply let the CiOX representative know.

Questions?
Please contact us with any questions or concerns you may have. You can call your Provider Network representative, or you’re welcome to contact Patricia Grady, HEDIS Program Manager, at (541) 330-7331 or Patricia.Grady@pacificsource.com.  

Facility Claims Require Full Code Number

Effective January 26, 2017, PacificSource will start denying facility claims that are billed without the required 4th/5th digit. If the DX code requires it and the provider didn’t bill it, the entire claim will deny (regardless of where the DX falls on the claim – could be primary DX or could be the 5th DX). This is already being done on Medicare/Medicaid facility and professional claims, and will now apply to facility claims for our commercial members. These incorrectly coded claims have an impact on reporting and risk adjustment. Please contact your Provider Service Representative if you have any questions.  

NDC Codes Required for Drug Claims Starting February 1

Effective February 1, 2017, we will require National Drug Code (NDC) numbers on all drug-related HCPC/CPT codes, including unlisted drug codes. Please see our NDC FAQ for details.

Are Your Claim CPT Codes Up to Date?

Please double check your claim CPT codes to make sure they are current. Beginning January 1, 2017, claims with termed CPT codes will be denied. Note that there is no longer a grace period.

PacificSource and Legacy Health – A Partnership to Build a Healthier Future for Northwest Communities

10/26/15 - We’re proud to announce that PacificSource Health Plans and Legacy Health are pursuing a partnership to bring together complementary capabilities. Our shared vision of healthcare focuses on improving the experience of care, reducing healthcare costs, and improving the health of our communities.

Ultimately, this partnership was driven by both organizations’ commitment to serve both members and patients.

Important Things to Know about this Partnership

  • We will maintain all our provider partnerships. We will continue to work with all our existing provider partners throughout Oregon, Idaho, and Montana. We will also continue to pursue future relationships with other healthcare providers.
  • No change to existing provider contracts, processes, policies, programs, or staff. Please be assured that our processes, such as preauthorization and claims payment, will continue as usual. In addition, our name and brand will remain the same.
  • For members, nothing has changed. Members will continue to receive the same outstanding benefits and unmatched customer service that have been hallmarks of PacificSource since 1933.
  • As we move forward, the partnership will provide the foundation for improvements and enhancements. This includes increased access to care for communities, the creation of new and unique health plan offerings, and industry-leading stability in a volatile health insurance market.

Looking for more information? You’re welcome to read the news release or our FAQ for providers to learn more about Legacy Health and this partnership.

Healthcare Reform 

Questions about the Affordable Care Act? You'll find information, FAQs, and links to online resource in our  Healthcare Reform Resource Center.

 

InTouch for Providers

Access your PacificSource account information 24/7.

Medicaid Dental Providers

Learn more about our contracted dental provider networks for Medicaid dental services.

Learn more >

Dental Providers: Join Advantage Dental Today

Advantage Dental is the exclusive network for PacificSource Health Plans, and we’re growing throughout the Northwest. As a participating provider, you’ll enjoy the benefit of increased patient access. The contracting process is easy, and there are no fees to participate! 

To get started, go to Secure.AdvantageDental.com/Credentialing.

Your Provider Service Representative

Your PacificSource Provider Service Representative is available any time you have a question or concern. If you're not sure who your representative is, please visit our Provider Service Staff Directory.

Last updated 11/7/2018