PRV1_0119_ProviderManual-Commercial.pdf

Pacificsource considers nonsurgical treatment of

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PacificSource considers nonsurgical treatment of sleep disorders to be medically necessary when all of the following are met: A PSG or HST sleep study documented AHI or RDI 10 episodes per hour of sleep OR An AHI or RDI between 5 and 9 plus any of the following associated symptoms: Excessive daytime sleepiness, as documented by either a score of 10 on the Epworth Sleepiness Scale or inappropriate daytime napping (e.g., during driving, conversation, or eating) or sleepiness that interferes with daily activities; OR Impaired cognition OR Mood disorders OR Documented hypertension OR Documented ischemic heart disease OR Documented history of stroke CPAP or BiPAP trial rental is covered for an initial 3 months to determine tolerance and appropriate utilization before purchase will be approved. Conversion to purchase of CPAP or BiPAP machine is covered with receipt of the “Request for Purchase” form documenting compliance and efficacy of treatment on the follow-up visit with the specialist. This form is submitted with the claim for purchase. In the case of providers whose billing agent is not at the provider location, the form may be submitted to the Claims department separately. If continued rental (rather than purchase) of CPAP/BiPAP is desired, preauthorization through Health Services is required. When a participating provider is not available in the members service area, services will be payable at the contracted benefit rate (Use code A36 on preauthorization request).
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Section 6 | Medical Management 32 6.3.4 Preauthorization Procedure The PacificSource Health Services department is ready to assist physicians, providers, and office staff with preauthorization services, and is available to answer questions. When all pertinent information needed to make a decision has been received, the preauthorization request will be processed according to the turnaround times established by state laws and regulations. You may reach the department in one of the following ways: Telephone Oregon: (541) 684-5584, toll-free (888) 691-8209, ext. 2584 Idaho: (208) 333-1563, toll-free (800) 688-5008 Montana: (406) 442-6595, toll-free (877) 570-1563 Fax Oregon: (541) 225-3625 Idaho: (208) 333-1597 Montana: (406) 441-3378 Address PacificSource Health Plans Health Services Department PO Box 7068 Springfield, OR 97475 For specific benefit information, please contact our Customer Service department by phone at (541) 684-5582 or toll-free at (888) 977-9299, or by email at [email protected] Alternatively, you may call our toll-free customer service phone line especially for commercial providers at (855) 896-5208 to verify member benefits. Preauthorization requests may be submitted as follows: For MRI, CT, and PET scans, through AIM (American Imaging Management). Go online to the AIM web portal at americanimaging.net/goweb, or submit preauthorization requests via the call center at (877) 291-0510.
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  • Winter '16
  • Dr. Vincent Onyebuchi
  • PacificSource

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