ProviderSource - PacificSource

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New Large Employer Clients To keep you informed of potential new patients, as well as possible coverage changes for existing patients, we publicize large employers that have recently enrolled with us. Covered Lives* Effective October 1, 2009 Location 46 Umpqua Research Company Myrtle Creek 61 Women’s Health Center of Southern Oregon PC Grants Pass 58 Whitewater Construction Eugene 115 JCK Restaurants, Inc. DBA Carl’s Jr. Eugene 100 Metro Overhead Door, Inc. Portland 49 Big Country RV, Inc. Bend 40 Clarke’s Sheet Metal, Inc. Eugene 50 High Desert Automotive Supply, Inc. DBA Napa Auto Parts 44 Petersen Kolberg and Associates DBA PKA Architects Bend Portland 52 Seventh Mountain Resort Bend Covered Lives* Effective November 1, 2009 Location 52 Northwest Surgical Specialists, LLP Springfield 50 Highland Laboratories, Inc. Mt. Angel 128 Rosen Aviation, LLC Eugene 213 Performance Health Technology LTD Salem 60 Ehlers Construction, Inc. Eugene 69 Marshalls, Inc. Springfield 106 Healthco Information Systems Tualatin 64 AFP Systems, Inc. Tualatin 108 Yorke and Curtis, Inc. Beaverton 352 A and M Transport, Inc. Glendale 35 The Maren Corporation Eugene Covered Lives* Effective December 1, 2009 64 Rainbow Valley Design and Construction, Inc. Location Eugene 50 Daniel N Gordon PC Eugene 41 The Hasson Company Clackamas 57 Elcon Associates, Inc. Portland 44 Westside International Medicine PC Portland 112 Davies, Inc. Salem 43 Western Panel Manufacturing, Inc. Eugene 41 Ken Ware Chevrolet, Inc. OADA North Bend PacificSource Performance At a Glance - December ‘09 Enrollment Total Enrollment: 207,149 Medical Members: 173,588 Dental Members: 66,406* * This number includes members with dental only as well as those that have both dental and medical coverage with PacificSource. Claims Processing Actual Target Turnaround Time: 13 days 10 days Accuracy: 97% 99% Customer Service Actual Target Answer Speed (seconds): 24 25 Abandonment Rate: 2% 2% Customer Satisfaction Actual Target Member Satisfaction: 95% 95% Provider Satisfaction: 100% 95% * Covered lives references the approximate total of enrolled employees plus their enrolled dependents. Benefit information is printed on the patient’s ID card. If you have any questions, please feel free to contact our Customer Service Department. 4
Administrative News & Important Reminders Oregon Legislation Brings Changes to Autorecovery Process Prior to 2010, our process for collecting refunds varied based on the terms of your provider contract. In some cases refunds were autorecovered, and in others they were requested in writing. Effective January 1, 2010, Oregon Senate Bill 508 states that providers must be provided a refund request in writing 60 days prior to autorecovery. To comply with the new law, our new policy will apply to all providers and will override any contract language. Our new refund policy is as follows: 1. We send you (the provider) an initial refund request. 2. 30 days from initial request: If we have not received the refund, or if you have not contested the refund within this timeframe, we will send a reminder (second refund request). 3. 60 days after the initial request: If we have still not received the refund, the overpayment will be autorecovered on the next scheduled payment. To contest a refund, PacificSource requires the use of our Contested Refund Form, available on PacificSource.com under For Providers > Forms and Materials. In addition to the form, supporting documentation is required to contest the refund. Examples of documentation include: • A new primary EOP in cases where a primary insurance payer decides to reprocess their claim • Chart notes that support the original payment • Preauthorization obtained, which allows the original payment to stand Telemedicine Coverage Effective January 1, 2010, in accordance with Oregon Senate Bill 24, we are now covering Telemedicine services under all of our fully insured plans (except Short Term Medical). Coverage for self-insured plans (under PacificSource Administrators, Inc.) will vary. To bill PacificSource for Telemedicine services, the following codes will be accepted: 0188T, 0189T, G0406, G0407 and G0408, plus any covered procedure code with a GT modifier. To determine coverage for any other code not listed here, please contact your Provider Service Representative. Guidelines for Using Modifier 25 Our policy for Modifier 25 states that if you provide both a service/procedure and E&M (evaluation and management) on the same day, they must be significant, separate, and identifiable. Documentation must support both services and show that the E&M was above and beyond the service or procedure provided. Please include a chart note for each service and confirm that the same patient received both services. Please note that when we receive a claim that includes a preventive care charge and an office visit charge, the claim will be pended while our Claims Research Analyst reviews the attached chart notes. 5 If no notes are present, the charges for the office visit will be processed as provider write-off with the explanation code stating that allowable charges are limited to one office or hospital visit per day, and that the patient is not responsible for the difference. Examples of when both charges would not be appropriate: • A patient who has a history of hypertension is scheduled for a routine physical. You make brief mention of the hypertension and re-fill the patient’s prescription. • During an annual gynecological exam, a patient mentions that she is having hot flashes, and you order blood work to check hormone level. • A child is seen for a well-child checkup and you note that he has an ear infection and prescribe antibiotics. Examples of when both charges would be appropriate: • A patient is scheduled for a routine physical with a history of hypertension, and upon examination, you discover that the patient’s blood pressure is extremely high. The patient says he is having lightheadedness and ringing in the ears. You take measures to reduce the blood pressure and counsel the patient on how to monitor the condition. • During an annual gynecological exam, you find a lump in a patient’s breast and order additional blood work and radiological procedures. You also take additional time to go over treatment options with the patient. Board Certification Reminder for Oregon Providers When submitting an application to PacificSource for new physicians or nurse practitioners joining your clinic, please remember to include board certification information noted on page 2, section 4 of the Oregon Practitioner Credentialing Application. If your new practitioner is a new graduate or the certification is in process or pending, please indicate that as well. PacificSource has found board certification to be one useful benchmark of quality and competency. As you know, board certification is a nationally recognized attestation of basic qualifications in one’s specialty. In addition, industry standards increasingly emphasize it as a prerequisite for providers’ health plan participation. Please be aware that our Credentialing Committee may consider loss of certification, repeated failure to pass certifying exams, or other deficiencies as grounds for not accepting an application for credentialing or recredentialing. Old Code Books? Consider Donating Them. If you have 2009 medical code books taking up space in your office, why not put them to good use? Check with your local college to see if they have a program that might need these resources. As you know, code books are expensive, and in many cases students only need them for one class, so purchasing them can be a burden.
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