PRV1_0119_ProviderManual-Commercial.pdf

Electronic prior notification 2019 beginning in 2019

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Electronic Prior Authorization/Inpatient Notification 2019 Beginning in 2019, PacificSource Health Plans will no longer be accepting prior authorization (PA) requests via fax or U.S. Mail. Instead, we ask that you submit prior authorization requests via our provider portal, InTouch. We will be making outreach to your offices to assist you in getting an account created, and assist with any training. If you do not have access to InTouch, please visit and register. Here is a link with some more information about InTouch as well: PacificSource.com/aboutproviderintouch. In some cases, your billing office may be using it already. If so, you can contact them to find out who your administrator is on the account, and they can contact OneHealthPort to have additional users added. This can include front desk personnel or anyone who needs to submit PAs. Please do not hesitate to contact your Provider Service Representative should you have any questions. We will be happy to assist you in any training you might need to utilize this portal. Please note, preauthorization is to establish medical necessity, this does not override our system clinical edits. The following information is necessary to complete a request: • Date • Patient’s name • Date of birth • Member number & group number • CPT/HCPCS code and description • Durable medical equipment: rental or purchase (if applicable) • Date of service • Expected length of stay (if applicable) • Place of service or vendor name • Assistant surgeon requested (yes or no, if applicable) Prior authorization determinations are made within two business days for nonurgent preservice requests • Diagnosis codes (ICD-10) and description
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Section 6 | Medical Management 33 • Ordering physician/provider and office location (first and last names please) • Contact person and telephone number (first and last names please) • Referring physician (first and last names please) 6.3.5 Retrospective Preauthorizations Effective August 1, 2013, PacificSource, through its Health Services department and processes, will review clinical documentation to ensure the appropriate claims adjudication for certain services that have been provided when coverage of this service was not preauthorized as contractually required. This includes requirements defined in both the member and provider contracts. Retrospective review determinations will be based solely on the medical information available at the time the service was provided. Results from subsequent testing or procedures cannot be considered. All retrospective requests for authorization are completed within 30 calendar days from receipt of all necessary clinical information. 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.
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  • Winter '16
  • Dr. Vincent Onyebuchi
  • PacificSource

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