PacificSource Community Solutions is the OHP CCO for Central Oregon (Crook, Deschutes, Jefferson and northern Klamath), the Columbia Gorge (Hood River, Wasco) and Marion-Polk. It did not renew its Lane County contract after 2025. Unlike most CCOs, it publishes a written ABA clinical guideline with a separate Oregon Medicaid section, which says it "follows Guideline Notes 75 and 126 of the OHP Prioritized List of Health Services and OARs 410-172-0650, 410-172-0760, and 410-172-0770."
PacificSource’s guideline (operations approval March 2026, next review January 2027) sets the Medicaid rules. The assessment must be recommended and referred by a practitioner described in OAR 410-172-0760: a physician, psychologist, or developmental-medicine nurse practitioner or physician associate experienced in autism (or, for stereotyped movement disorder, a licensed practitioner trained in it). "For an initial assessment for ABA services, a prior authorization (PA) is not required if CPT code 97151 is billed for 32 or fewer units (8 hours or less)"; more than 32 units requires PA and MD review with the diagnosis and documentation of the intensity requested. 97152 supports but does not replace the QHP assessment, and requests above 16 units in six months need justification.[2][3]
Treatment requests run in increments of up to six months, with a 32-unit limit on 97151 per authorization. Coverage follows Guideline Notes 75 and 126 and the OARs, including an ASD diagnosis on the HERC ASD line and a treatment plan with a functional assessment from a licensed health care professional, a licensed behavior analyst or assistant behavior analyst, or a declarant. "Requests for over 40 hours per week of treatment require MD review." PacificSource announced in 2023 that, from January 1, 2024, its plans require prior authorization for 97151–97158, 0362T and 0373T, submitted through InTouch (preferred) or by fax.[2][3]
OHA’s managed-care billing rule binds every CCO, PacificSource Community Solutions included (OAR 410-141-3565, effective January 1, 2025). Initial claims are due "within no more than 120 days of the date of service," or within 365 days for pregnancy, retroactive eligibility, Medicare as primary payer, third-party liability and other delays not caused by the provider; a CCO "may negotiate terms within this timeframe," so your contract can set a shorter limit but not a longer one. For a timely claim that needs correction or resubmission, the CCO must allow "a minimum of 180 days after the initial adjudication date." Other insurance "must be exhausted prior to payment." On payment, CCOs "shall pay or deny at least 90 percent of valid claims within 30 days of receipt and at least 99 percent of valid claims within 90 days of receipt," make an initial determination on 99 percent within 60 days, and "may not require providers to delay claims submission." The rule sets no weekly payment cycle or submission cutoff.[1]
The questions that decide whether a family can start with PacificSource Community Solutions (Oregon), and what they have to bring. Each maps onto something intake should ask on the first call.
No age limit in the Medicaid section; coverage follows Guideline Note 75 (intensive ABA for ages 1–12, targeted ABA from 13) and OAR 410-172-0770, which requires services beyond the guideline note when medically appropriate "including individuals age 13 and older." Under 21, EPSDT bars age-group-wide denials.[2][17][7][16]
PacificSource sets no recency rule. The OHP rule dates only the physical exam and hearing test (OAR 410-172-0770(1)(h)–(i)).[2][7]
For Medicaid, the OAR 410-172-0760 practitioners: a physician, psychologist, or nurse practitioner or physician associate specializing in developmental medicine, experienced in autism.[2][6]
The Medicaid section incorporates OAR 410-172-0770: a standardized, validated tool such as the ADOS and developmental status on assessments such as the Vineland. (The commercial section lists STAT, ADOS-2, ADI-R, CARS-2 and GARS-3.)[2][7]
Yes: ABA services must be "recommended and referred by a licensed practitioner as outlined in OAR 410-172-0760."[2][6]
PacificSource’s ABA guideline publishes no telehealth rule. The state rule applies: "For purposes of behavioral health services, the Authority shall provide coverage for telemedicine services to the same extent that the services would be covered if they were provided in person" (OAR 410-172-0850(5)), using synchronous two-way video (telephone and e-mail only where HERC guidelines allow). OHA’s behavioral health fee schedule lists modifier GT ("Via Interactive Simultaneous Audio and Video Telecommunication Systems") as an allowable modifier on every ABA code it prices, 97151 through 97157, including the 97151 assessment and 97155 protocol modification.[2][10][11]
PacificSource publishes no ABA-specific clock in its guideline. The CCO rule applies: notice "no later than seven (7) calendar days following receipt," expedited within 72 hours, one 14-day extension (OAR 410-141-3835).[2][12]
PacificSource’s ABA guideline adds nothing on other insurance, so the state rule applies. Medicaid pays last. OHA must be "the payer of last resort," and "Providers shall make reasonable efforts to obtain payment first from other resources" (OAR 410-120-1280; 42 CFR 433.139). Bill the commercial plan first and follow its authorization rules.[2][15][19]
Coverage decides whether PacificSource Community Solutions (Oregon) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
PacificSource’s commercial criteria require treatment "supervised and managed by a Board-Certified Behavior Analyst (BCBA)"; its Medicaid section adds no ratio, so the OHP rule applies. OHA does not pay assistant behavior analysts or registered behavior analysis interventionists directly (OAR 410-172-0760(4)); they work under a directly payable Licensed Behavior Analyst, licensed health care professional or declarant. The licensing rule sets the interventionist supervision floor: direct and indirect supervision "for at least 5 percent of the interventionist’s service hours," including direct supervision at least once per calendar month, by a licensed behavior analyst, licensed assistant behavior analyst or licensed health care professional (OAR 824-040-0010). Direct supervision may be remote if it is synchronous audio and video (OAR 824-010-0005).[2][6][14]
97151: up to 32 units per authorization without MD review (no PA at all for an initial assessment of 32 units or fewer); 97152 above 16 units in six months goes to review; treatment over 40 hours a week requires MD review. The commercial section states "ABA cannot exceed 40 hours (4,160 combined units) a week" (as printed).[2]
The guideline points to PacificSource’s Documentation Requirements for Health Practitioners policy (member identification, participants, problem list, measurable progress, treatment provided, follow-up plan) but sets no signature rule. The OHP floor applies: each note "signed or initialed by the individual providing the service" (OAR 410-172-0620(4)).[2][9]
PacificSource publishes no rendering-provider rule; its Medicaid treatment plans must come from a licensed health care professional, licensed behavior analyst or assistant, or declarant. The OHP payment rule applies: only a Licensed Behavior Analyst, licensed health care professional or declarant is eligible for direct payment (OAR 410-172-0760(3)–(4)).[2][6]
Not addressed in PacificSource’s ABA guideline.[2]
Ask the plan: PacificSource Community Solutions Provider Services (number on the member card) or your participation agreement.
Not addressed in PacificSource’s ABA guideline.[2]
Ask the plan: PacificSource Community Solutions Provider Services: ask which settings and place-of-service codes it pays for ABA.
120 days from the date of service under OAR 410-141-3565 (365 days for exceptions such as retroactive eligibility, Medicare or other insurance primary); your contract may set a shorter limit. Corrections and resubmissions get at least 180 days from the initial adjudication.
Not if 97151 is billed for 32 units (8 hours) or fewer. Above 32 units it needs PA and MD review.
Requests can be made in increments of up to six months.
No. PacificSource did not renew its Lane County CCO contract after 2025; most Lane members moved to Trillium on February 1, 2026.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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