---
title: "PacificSource Community Solutions ABA coverage: the intake guide."
url: "https://carelu.com/payers/pacificsource-community-solutions-oregon"
markdown_url: "https://carelu.com/payers/pacificsource-community-solutions-oregon.md"
state: OR (Oregon)
payer: PacificSource Community Solutions (Oregon)
kind: Medicaid managed care plan (MCO)
parent_program: Oregon Health Plan (Coordinated Care Organizations)
description: "How PacificSource Community Solutions covers ABA for OHP members in Central Oregon, the Columbia Gorge and Marion-Polk: its written Medicaid ABA policy, the 32-unit assessment threshold, six-month authorizations, MD review triggers, and what intake should collect."
last_reviewed: October 2026
---

# PacificSource Community Solutions ABA coverage: the intake guide.

_Payer Guide · PacificSource Community Solutions · Oregon · Last updated October 2026 · 18 primary sources_

> CCO for Central Oregon, Columbia Gorge and Marion-Polk with a written Medicaid ABA policy: no PA for 97151 up to 32 units, six-month treatment PAs.

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."

This plan administers the **Oregon Health Plan (Coordinated Care Organizations)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Oregon Health Plan (Medicaid) guide](https://carelu.com/payers/oregon-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not for a standard assessment: PA "is not required if CPT code 97151 is billed for 32 or fewer units (8 hours or less)"; above 32 units, PA and MD review. 97152 above 16 units in 6 months goes to medical necessity review [2]
- **Prior auth for treatment**: Yes: "Prior Authorization is required for ABA services," requested in increments of up to six months; over 40 hours a week needs MD review [2][3]
- **Autism diagnosis required?**: Yes: an ASD diagnosis "listed on the ASD line" of the Prioritized List, or Stereotypic Movement Disorder with Self-Injurious Behavior; ABA is "experimental, investigational, or unproven" for other diagnoses [2]

## At a glance

- **Covers ABA?:** Yes: ASD and Stereotypic Movement Disorder with Self-Injurious Behavior
- **Service areas:** Central Oregon, Columbia Gorge, Marion-Polk (Lane County ended after 2025)
- **Assessment PA:** None for 97151 up to 32 units (8 hours); PA + MD review above that
- **Treatment PA:** Required, up to six months per request
- **MD review:** Over 40 hours/week of treatment, or over 32 units of 97151
- **Submit via:** InTouch (preferred) or fax

## The Medicaid ABA policy

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]

## Claim filing and payment rules for PacificSource Community Solutions

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]

## Intake gates

The questions that decide whether a family can start with PacificSource Community Solutions (Oregon), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Referral required?**: Yes: ABA services must be "recommended and referred by a licensed practitioner as outlined in OAR 410-172-0760." [2][6]
- **Telehealth**: 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]

## Delivery and billing rules

Coverage decides whether PacificSource Community Solutions (Oregon) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: 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]
- **Daily limits / MUEs**: 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]
- **Session-note signature**: 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]
- **Bill as provider**: 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]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.
- **Place of service** _(ask the plan)_: 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.

## What intake should collect for PacificSource Community Solutions (Oregon)

- **Member ID and region:** Confirm PacificSource Community Solutions (Central Oregon, Columbia Gorge or Marion-Polk). Lane members are now with Trillium.
- **Referral:** From a physician, psychologist, or developmental-medicine NP/PA experienced in autism (OAR 410-172-0760).
- **Diagnosis:** ASD on the HERC ASD line, or Stereotypic Movement Disorder with Self-Injurious Behavior.
- **Treatment plan with functional assessment:** From an Oregon-licensed behavior analyst or other qualified licensee; requested in up to six-month increments.
- **Other insurance:** Bill commercial coverage first; OHP is the payer of last resort.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### What is PacificSource Community Solutions’s timely filing limit for ABA claims?

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.

### Does PacificSource Community Solutions require prior authorization for the ABA assessment?

Not if 97151 is billed for 32 units (8 hours) or fewer. Above 32 units it needs PA and MD review.

### How long are PacificSource ABA authorizations?

Requests can be made in increments of up to six months.

### Does PacificSource still cover OHP members in Lane County?

No. PacificSource did not renew its Lane County CCO contract after 2025; most Lane members moved to Trillium on February 1, 2026.

## Primary sources

1. [OAR 410-141-3565 — Managed Care Entity Billing (OHA, DMAP 143-2024, eff. 01/01/2025): §§ (1)(a)–(c), (6), (8)(b), (8)(d)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-141-3565)
2. [PacificSource Clinical Guideline — Applied Behavioral Analysis (ABA), Commercial and Medicaid (Oregon Medicaid section; Ops approval 3/2026, next review 1/1/2027)](https://pacificsource.com/media/24381)
3. [PacificSource — ABA treatment services and neuropsychological and psychological testing will require prior authorization (Sept. 29, 2023; eff. 1/1/2024)](https://pacificsource.com/article/aba-treatment-services-and-neuropsychological-and-psychological-testing-will-require-prior)
4. [OHA — Coordinated Care Organization (CCO) Plans (CCO list by county, read from the page’s CCO Plan Details list)](https://www.oregon.gov/oha/HSD/OHP/Pages/Plans.aspx)
5. [OHA — Lane County CCO Transition: Reminder for Members (updated 03/23/2026)](https://www.oregon.gov/oha/HSD/OHP/Tools/Lane-County-Transition-Member-Reminder-EN.pdf)
6. [OAR 410-172-0760 — Applied Behavior Analysis (OHA, eff. 01/09/2025)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-172-0760)
7. [OAR 410-172-0770 — Individual Eligibility for Applied Behavioral Analysis Treatment (OHA, DMAP 12-2017)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-172-0770)
8. [OAR 410-172-0650 — Prior Authorization, Medicaid behavioral health (OHA, eff. 06/21/2022)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-172-0650)
9. [OAR 410-172-0620 — Documentation Standards, Medicaid behavioral health (OHA, eff. 6/26/2015)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-172-0620)
10. [OAR 410-172-0850 — Telemedicine for Behavioral Health (OHA, DMAP 67-2018)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-172-0850)
11. [OHA — OHP Fee-for-Service Behavioral Health Fee Schedule, Applied Behavior Analysis tab (update published 7/1/2026)](https://www.oregon.gov/oha/HSD/OHP/DataReportsDocs/bh-fee-schedule0726.xlsx)
12. [OAR 410-141-3835 — CCO Service Authorization (OHA, eff. 07/01/2026)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-141-3835)
13. [OAR 410-141-3565 — Managed Care Entity Billing (OHA, eff. 01/01/2025)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-141-3565)
14. [OAR 824-040-0010 — Training and Supervision of registered behavior analysis interventionists (eff. 2/1/2018)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=824-040-0010)
15. [OAR 410-120-1280 — Billing (third-party resources; OHA as payer of last resort)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-120-1280)
16. [OHA — EPSDT Provider Guide (March 2026)](https://www.oregon.gov/oha/HSD/OHP/Tools/EPSDT-Provider-Guide.pdf)
17. [HERC — Prioritized List Guideline Notes, 10/1/2026 (Guideline Note 75 ABA for ASD, Line 192; Guideline Note 126 ABA for self-injurious behavior, Line 436)](https://www.oregon.gov/oha/HPA/DSI-HERC/PrioritizedList/10-1-2026GL.txt)
18. [PacificSource Community Solutions — Medicaid News and updates (provider notices archive)](https://pacificsource.com/medicaid/resources/articles)
19. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/api/renderer/v1/content/enhanced/current/title-42?part=433&section=433.139)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.