Questions About Your Plan?

Here's a quick reference to important information about your PacificSource plan. You're always welcome to contact us if you have questions. 

Quick Links to Sections Below

Find Out What Your Plan Covers

In addition to the general information on this page, your PacificSource member handbook or policy provides specific information about benefits and services covered by your plan. Your specific, detailed plan information is available to you 24/7 online through our secure member portal, InTouch for Members. You'll need to register when you use InTouch for the first time. All you need to register is a valid email address, your member ID number (you'll find this on your member ID card), or your social security number.

Register for InTouch for Members >

Getting the Care You Need

After Hours or Emergency Care

 

If you have a true medical emergency, always go directly to the nearest emergency room, or call 911 for help.

If you're facing a non-life-threatening emergency, contact your doctor's* office, or go to an urgent care facility. Urgent care facilities are listed in our online provider directory. Simply enter your city and state or zip code, then select "Urgent Care" in the "Specialty Category" field. 

*Don't have a doctor right now? Let us help you find one >

Health-related Questions

 

Call our 24-Hour NurseLine: (855) 834-6150.

Staffed around the clock, seven days a week, you'll never be without a registered nurse to talk to when you have health-related questions.

Your ID Cards

 

Always show your ID card at your doctor's office or pharmacy. Your ID card gives providers the information they need to submit claims on your behalf.

If you're a new member:

If you haven't already received one, a member ID card will be mailed to your home soon. If you need to order prescriptions or access medical services before your new ID card arrives, you can print a temporary ID card.

Note: Your plan must be active in order to print an ID card. If your plan starts at a future date (for example, the first of next month), you'll need to wait until that date to print a temporary ID card.

If you're a current member:

Please call Customer Service or visit InTouch for Members to request a new ID card. From InTouch, you can also print a temporary ID card to use until your replacement card arrives.

Note: Your temporary ID card will only show your eligibility in effect on the day you print your card. If you are a renewing member and have upcoming changes to your plan, your new eligibility will show on your temporary card only after your plan's renewal date.

Log into InTouch >

New to InTouch? Register now >

Flu Shot Coverage

 

Flu shots are typically covered by your PacificSource plan. Learn more at PacificSource/flu.

Covered Benefits and Services

 

Your PacificSource member handbook or policy provides specific information about benefits and services covered by your plan.

This information is available to you 24/7 online through our secure member portal, InTouch for Members. You'll need to register when you use InTouch for the first time. You'll find a link to the registration page on PacificSource.com. All you need is a valid email address, your member ID number (you'll find this on your member ID card), or your social security number.

If you have a question about your benefits, you're welcome to contact Customer Service.

Benefit Exclusions

 

Your plan may exclude some procedures, services, and medications. You'll find information specific to your plan in your member handbook or policy. Your member handbook or benefits summary is available to you online 24/7 through your InTouch account.

You're welcome to contact Customer Service if you have questions or need assistance. 

Costs You May Have to Pay

 

To learn more about what costs you may have to pay as part of your plan, such as copayments and deductibles, see your member handbook or benefit summary. These documents are available to you online 24/7 through your InTouch account.

You're also welcome to contact Customer Service for assistance.

Premium Refund

 

If for any reason the policyholder, policyholder estate or entity cancels coverage under this policy, the policyholder, policyholder’s estate or entity shall notify PacificSource on a timely basis. PacificSource will refund to the policyholder, policyholder’s estate or entity any unused premium received for the period of ineligibility.

‘Unused collected premium’ means that portion of any premium collected which is not used, on a pro-rata basis to the beginning of the next billing cycle at the time of cancellation, by PacificSource to insure against loss when there is no risk of loss, or that portion of any collected premium which would have not been collected had the policyholder paid monthly.

If your coverage is through an employer group plan, contact your employer to request a refund due to premium overpayments.

If you are an individual policyholder, we issue premium refunds within 30 days of your request or cancellation of your policy. Refunds due to cancellations are processed automatically, and do not require any action from the policyholder. Refund requests due to overpayment of premium can be made via written request, email, or phone. Contact the Membership Services Department toll-free at (800) 591-6579, by email at membership@pacificsource.com , or by mail at 

PacificSource Health Plans
PO Box 3389
Portland OR 97208-3389  

Reading Your Explanation of Benefits (EOB)

 

Your EOB is a summary of recent services you've had, such as a doctor visit or lab work. It tells you how much the doctor billed, how much your plan paid, and the balance, if any, you owe to your provider. You'll also find deductible balance and other information. If you have questions about how to read your EOB, check out our About Your EOB page

Your EOB statement will be sent to you after we have received a claim and processed it. Depending on the delivery method you have selected, you with either receive a paper statement by mail or receive an email notice. If you have question or want to check the status of a claim, your are always welcome to contact our Customer Service team.

Definitions of Common Terms

 

Check out our Glossary to find definitions to common terms, such as “co-pay,” “co-insurance,” and “preauthorization.”

Find a Doctor and Information about Doctors

 

Use our online Provider Directory to find a doctor or other provider, and more information about those doctors and providers.

To maximize your plan's benefits, always make sure your healthcare provider is a PacificSource participating provider. If your plan has more than one tier of participating providers (indicated in our online provider directory by tier 1 or tier 2), you'll get the most value from your plan by selecting a tier 1 provider. If you receive services from a nonparticipating provider, it may result in greater out-of-pocket costs to you. Please refer to your member handbook or policy, or log into InTouch, to find detailed information about out-of-network benefits and coverage.

Our online provider directory makes it easy to find participating healthcare providers for your plan (see your ID card, member handbook, or policy for your specific plan information). You can search by specialty, name, location, or other details to access a list of providers that fit your criteria. Or you can create your own personalized provider directory to download and print.

Primary care: While you're welcome to choose a primary care provider (PCP) for any of our plans, some plans require you to select one when you enroll. A primary care provider will work with you to help you maintain your health and reach your wellness goals. PCPs are identified in our online provider directory by a blue banner above the provider information.

Traveling? If you're traveling or live outside of Idaho, Montana, Oregon, and Clark, Cowlitz, Klickitat, Pacific, Skamania, and Wahkiakum counties in Washington, you have access to our travel networks. Information about these networks is available on our Find a Provider page, and in the FAQ section of our online Provider Directory.

For additional information about choosing a provider and accessing care, refer to your member handbook or policy.

Customer Service can also help you find doctors, dentists, and hospitals in your area and provide details about their services and professional qualifications.

Find a Specialist, Behavioral Health Provider, or Hospital

 

Our online Provider Directory makes it easy to find in-network specialists, behavioral health providers, and hospitals. Simply use the "specialty category" and "specialty" drop down menus to define what you're looking for.

Be sure to check your plan, as some plans require referrals from a primary care physician before visiting a specialist. Behavioral healthcare services do not require a referral. For non-emergency care, you and your doctor can select the right hospital for your needs.

You're also welcome to contact Customer Service for assistance.

Find a Specialist, Behavioral Health Provider, or Hospital >

Transitioning from a Pediatrician to a PCP

 

If you or someone on your health plan is 18 years old or turning 18 this calendar year, it’s time to consider transitioning to a primary care provider (PCP) for adults. This type of PCP can be a provider who specializes in family practice, general practice, geriatrics, internal medicine, or obstetrics-gynecology.

Why Choose a PCP

When you choose a PCP, you're partnering with a care provider you trust. This makes it easier to coordinate your care, achieve your health and wellness goals, and see the big picture of your health. If your plan doesn't require you to formally select a PCP, we still recommend you choose a provider to work with consistently to best coordinate your healthcare needs.

How to Designate a PCP

When you're ready, and if your plan requires you to choose a PCP, there are a couple of ways you can proceed:

  • Use our Provider Directory: Fill in the search fields as much as you'd like (only a zip code is required), and browse your results. You'll notice PCPs have a "Primary Care Provider" banner above their names. When you've chosen the provider you want, click the "Set as my PCP" button.
  • Contact Customer Service for Assistance: Our friendly Customer Service staff is happy to help you select your PCP.

 

Out-of-area Care and Benefits

 

When traveling out of our network service area, you have access to providers and facilities nationwide through our travel provider networks: First Choice Health (serving Alaska and all Washington counties except Clark, Cowlitz, Klickitat, Pacific, Skamania, and Wahkiakum) and First Health (serving all states except Alaska, Washington, Idaho, Montana and Oregon). You will receive your plan's participating provider benefits when you use First Choice Health and First Health providers for services outside your plan's service area.

Your member handbook or policy provides specific information about your plan's provider network and service area, which includes Idaho, Montana, Oregon, and the following counties in Washington: Clark, Cowlitz, Klickitat, Pacific, Skamania, and Wahkiakum.

Traveling internationally? Our International Travel flier provides helpful tips and information should you need to access care while traveling internationally.

Should you need emergency assistance while traveling more than 100 miles from home or abroad, you also have access to emergency travel assistance through Assist America.

Out-of-network Liability and Balance Billing

 

PacificSourse bases payment to non-participating providers on our “allowable fee,” which is derived from several sources, depending on the service or supply and the geographical area where it is provided. The allowable fee may be based on data collected from the Centers for Medicare and Medicaid Service (CMS), other nationally recognized databases, or PacificSource.

To calculate our payment to non-participating providers, we determine the allowable fee, then subtract the non-participating provider benefits shown in the ‘Non-participating Provider’ column of your Medical Schedule of Benefits. Our allowable fee is often less than the non-participating provider’s charge. In that case, the difference between our allowable fee and the provider’s billed charge is also your responsibility. That amount does not count toward this plan’s out-of-pocket maximum. It also does not apply toward any deductibles or co-payments required by the plan. In any case, after any co-payments or deductibles, the amount PacificSource pays to a non-participating provider will not be less than 50 percent of the allowable fee for a like service or supply.

Pharmacy Information

 

If your health plan includes a prescription drug benefit, you can receive your medications at a pharmacy near you. Here's how: 

  1. Find a pharmacy in your area.
  2. Show your PacificSource ID card when you drop off your prescription(s). 
  3. Pay your share of the drug's cost. PacificSource will be billed directly for the balance.

Learn more about using our pharmacy network.

If your medical plan uses our Preferred Drug List (PDL), our prescription discount program can help you save money on eligible medications that aren't covered, when you shop at a participating CVS Caremark® pharmacy. 

Find out which drugs are covered

See your member handbook or policy for information about your pharmacy coverage and which drug lists apply to your plan. Then, find your drug list on our drug list page.

Our drug lists are guides to help your doctor identify medications that can provide the best clinical results at the lowest cost. As a cost savings for you, generic drugs are included in place of name brand drugs whenever possible. Some drugs may require preauthorization, or be part of a step-therapy process. Step therapy requires the trial of one or more prerequisite medications before a step therapy medication is covered. Drugs not listed on our drug lists are not covered.

Drug lists are reviewed monthly. Recent changes can be found on our Drug News page, and more information about preauthorization and our step-therapy process on our drug list page.

Helpful links:

PacificSource Drug Lists — our comprehensive drug list page. You'll also find links to information about preauthorization and step therapy.

Prescription drug claim form  — use this if you needed to pay for a covered medication up front and need to be reimbursed

Preauthorizations for prescription drugs

PacificSource requires written preauthorization for coverage of certain medical services, surgical procedures, and prescription drugs. The term "preauthorization" simply refers to a process by which an insurer determines in advance whether or not a specific service or drug will be reimbursed.

Learn how preauthorization works >

To request a prescription drug preauthorization

Have your prescribing doctor complete our Prescription Drug Preauthorization Request form. Information about drugs that require preauthorization is available on our drug list page.

Limits and Quotas

Some plans may have limits or quotas for certain drugs. Refer to your member handbook or policy for more information, or contact Pharmacy Customer Service for help.

To request a prescription drug exception

If your drug is not included on the drug list on our drug list page, you should first contact Customer Service and confirm that your drug is not covered. You and your doctor have the right to request an exception to the plan’s formulary or coverage criteria. If you would like to request an exception, please have your doctor submit documentation through InTouch, fax, or phone using the Preauthorization/Medication Exception Request.

When considering drug exception requests, we review all pertinent information available and we may communicate with your healthcare provider if additional clinical information is needed.

We respond to preauthorization and exception requests from healthcare providers and members within two business days for standard requests. Expedited requests are addressed within 24 hours.

As soon as a determination is made, we mail notice of the decision to the member and fax the physician, and facility or vendor. You and your provider can also check the status of your request by Logging into InTouch, or by calling our Customer Service Department at (888) 977-9299.

Vision Services

 

We're pleased to be partnering with VSP to provide vision services as of January 1, 2015. VSP is now available for individual, small group, and large group members upon their plan's renewal, and will be available to self-funded group members in 2016.

Find a Vision Provider >

Manage Your Health and Benefits Online

Access Your Personal Benefit Information with InTouch

 

InTouch lets you access your insurance information and a wealth of health resources online. By logging in with a user name and password, you can access information about your PacificSource coverage 24 hours a day, right here on our website.

  • Look Up a Claim
  • See Plan Benefits
  • View Deductible or Balance
  • Pay Your Bill Online

Log into InTouch >

New to InTouch? Register now >

Learn More About Your Health with CaféWell

 

Taking the first step toward living a healthy life can be tough. That's why we've partnered with CaféWell—a secure health engagement portal that provides health and wellness resources, support, and guidance to our members and communities. With CaféWell, you can create a personalized plan based on your health goals, and get instant access to a variety of activities, wellness challenges, expert health coaching, and other health resources to support healthy life actions and choices.

Log into InTouch, and choose CaféWell >

New to InTouch? Register now >

Learn About Our Wellness Programs and Discounts

Wellness programs

 

As a PacificSource member, you have access to wellness programs as part of your medical coverage, such as InTouch Health Manager, our 24-Hour NurseLine, and our Prenatal Program.

Learn more >

Extra Benefits, Discounts, and Services

 

As a PacificSource member, you have access to extra benefits and services as part of your medical coverage, such as gym discounts, weight-loss programs, and travel assistance.

Learn more >

Learn About Our Health Plan Programs

How New Technologies Become Covered Services

 

New and emerging medical procedures, medications, treatments, and technologies are often marketed to the public or prescribed by physicians before FDA approval, or before research is available in qualified peer-reviewed literature to show they provide safe, long-term positive outcomes for patients.

To ensure you receive the highest quality care at the lowest possible cost, we review new and emerging technologies and medications on a regular basis. Our internal committees and Health Services staff make decisions about PacificSource coverage of these methods and medications based on literature reviews, standards of care and coverage, consultations, and review of evidence-based criteria with medical advisors and experts.

How to Access Personal Health Records

 

To access your personal health records, simply contact Customer Service. You'll also find the forms you need to authorize and restrict access on our For Members Forms and Materials pages (Idaho members, Montana members, and Oregon members) on PacificSource.com.

How to Get Help from a Case Manager

 

Case management is a service available to all PacificSource members who have complex medical conditions and require support to manage their healthcare needs. It is a service aimed at improving health outcomes, increasing member satisfaction with their healthcare, and reducing healthcare costs.

Our case managers are registered nurses and licensed mental health professionals with extensive clinical experience. They work collaboratively with you and your healthcare providers to provide improved clinical, humanistic, and financial outcomes for you.

Case management can be of great help to members experiencing a wide range of complex medical issues, such as: 

  • Extended hospital or skilled nursing care
  • Cancer diagnoses, especially those needing help with a new diagnosis
  • Children with special needs
  • Chronic and/or rare diseases and conditions
  • Eating disorders, such as Anorexia Nervosa or Bulimia Nervosa

If you think you might benefit from case management, you're welcome to contact our Health Services Department:

Monday – Friday, 8:00 a.m. to 5:00 p.m.

Oregon:

Phone: (541) 684-5584
Toll free: (888) 691-8209
Fax: (541) 225-3625

Idaho:

Phone: (208) 333-1563
Toll free: (800) 688-5008
Fax: (208) 333-1597  

Montana:

Phone: (406) 442-6595
Toll free: (877) 570-1563
Fax: (406) 441-3378  

TTY: (800) 735-2900
Language assistance: (541) 684-5456 or (800) 624-6052 ext. 1009
Email: Use the online form on our Contact Us page.

How to Get Support for a Chronic Condition

 

Our Condition Support Program offers education and support to members with asthma, diabetes, heart failure, chronic obstructive pulmonary disease, coronary artery disease, or juvenile diabetes at no additional cost.

This voluntary program is available to all PacificSource members with medical coverage. Members covered under self-funded (PacificSource Administrators) groups are only eligible if their employer has purchased the option. Other eligibility requirements may apply.

If you feel you or a covered family member may qualify for this program, and you have not yet been contacted by us, you're welcome to talk with a Health Services representative about your eligibility.

Toll-free: (888) 987-5805
Email: yoursupport@pacificsource.com.

Information About Our Quality Improvement Program and Progress Toward Goals 

 

Our Quality Improvement Program provides a framework to ensure members have access to high-quality healthcare that is effective, safe, and results in positive outcomes. The program is driven by our company values and our strategic goals and objectives: 

  • Embracing Triple Aim – enhancing patient experience and quality, cost effectiveness, and improving population health; 
  • Creating a supportive, simple, and convenient member experience; and 
  • Creating care management models that enhance, support, and coordinate with community-based services.

Our 2016 Annual Quality Improvement Work Plan encompasses more than 35 initiatives covering the areas of clinical quality improvement, service quality improvement, improvement of patient safety and coordination of care, and members' experience. We use internal and external benchmarks to identify areas for quality improvement projects as well as monitor and measure our ongoing performance.

View our PacificSource 2016 Quality Program Highlights and Progress.

Information About Our Utilization Management Program

 

Our Utilization Management Program is in place to ensure our members receive appropriate, effective, and efficient medical care. It includes medical services, medical equipment, and pharmacy.

Decisions regarding the provision of healthcare services are made under the following provisions: 

  • Utilization management decision-making is based only on appropriateness of care and service, and the existence of coverage. 
  • PacificSource does not specifically reward practitioners or other individuals for issuing denials of coverage. 
  • Financial incentives for utilization management decision-makers do not encourage decisions that result in underutilization.

The nurses, physicians, other professional providers, and independent medical consultants who perform utilization review services for your plan are not compensated or given incentives based on their coverage review decisions. There are no financial incentives for such individuals that would encourage utilization review decisions that result in underutilization.

PacificSource nurses, social workers, and physician reviewers are salaried employees of PacificSource, and contracted external physicians and other professional consultants are compensated on a per-case-reviewed basis or population management basis, regardless of coverage determinations.

Utilization Management Staff Availability

Health Services staff is available eight hours a day, on normal business days, to answer utilization management related questions.

Our hours are: Monday – Friday, 8:00 a.m. to 5:00 p.m.  

After Normal Business Hours

We accept emails and faxes after normal business hours. Calls after business hours are forwarded to our confidential voice mail. A Health Services representative will return calls, emails, and faxes the next business day if received before midnight. Calls, emails, or faxes received after midnight will be addressed that day, during business hours.

Oregon:

Phone: (541) 684-5584
Toll-free: (888) 691-8209
Fax: (541) 225-3625

Idaho:

Phone: (208) 333-1563
Toll-free: (800) 688-5008
Fax: (208) 333-1597  

Montana:

Phone: (406) 442-6595
Toll-free: (877) 570-1563
Fax: (406) 441-3378  

TTY: (800) 735-2900
Language assistance: (541) 684-5456 or (800) 624-6052, ext. 1009
Email: Use the online form on our Contact Us page.

Learn More About Coordination of Benefits (COB)


Information About Coordination of Benefits

 

We will be secondary whenever the rules do not require us to be primary. When we are the secondary plan, we do not pay until after the primary plan has paid its benefits. We will then pay part or all of the allowable expenses left unpaid, as explained below. An ‘allowable expense’ is a health care expense covered by one of the plans, including copayments, coinsurance, and deductibles.

  • If there is a difference between the amounts the plans allow, we will base our payment on the higher amount. However, if the primary plan has a contract with the provider, our combined payments will not be more than the amount called for in our contract or the amount called for in the contract of the primary plan, whichever is higher. Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) usually have contracts with their providers.
  • We will determine our payment by calculating the amount we would have paid if we had been primary, and apply that calculated amount to any allowable expense that is left unpaid by the primary plan. We may limit our payment by any amount so that, when combined with the amount paid by the primary plan, the total benefits paid do not exceed the total allowable expense for your claim. We will credit any amount we would have paid in the absence of your other health care coverage toward our own plan deductible.
  • If the primary plan covers similar kinds of health care expenses, but allows expenses that we do not cover, we may pay for those expenses.
  • We will not pay an amount the primary plan did not cover because you did not follow its rules and procedures. For example, if your plan has reduced its benefit because you did not obtain pre-certification, as required by that plan, we will not pay the amount of the reduction, because it is not an allowable expense.
 

Learn More About Preauthorization


What is preauthorization?

 

Preauthorization is prospective review of a proposed healthcare treatment to determine availability of insurance benefits, medical necessity, and appropriateness. Sometimes it also includes assessment of the level of care and treatment setting.

Certain medical services and prescription drugs require preauthorization in order to be considered for coverage under your plan. In those cases, your provider is to obtain preauthorization from PacificSource before the treatment is provided. Failure to preauthorize when required may result in you being held responsible for payment to your provider if the services aren't covered by your plan.

Preauthorization is a service for you and your healthcare provider that helps:

  • Determine insurance benefits and provider contract status 
  • Optimize the quality of your care 
  • Anticipate and plan for any additional services that might be needed 
  • Facilitate timely payment of claims 
  • Identify opportunities for PacificSource case management or disease management programs
 

How will I know if my upcoming procedure requires preauthorization?

 

You'll find an up-to-date listing of the types of services that require preauthorization on our website. If your procedure isn't specifically listed but might fall under one of the broad categories on our preauthorization list—such as experimental or investigational procedures—it will require further inquiry. PacificSource Customer Service can verify whether a procedure requires preauthorization if we have your procedure's billing code. Ask your provider to call us to check on preauthorization.

Do I need a preauthorization or referral for mental health care?

 
  • Outpatient mental health and chemical dependency services do not require preauthorization; you may self-refer to eligible providers. For our members with significant care needs, we conduct concurrent review and may request a treatment plan from the treating provider for case management purposes. 
  • Preauthorization and concurrent review is required for inpatient, residential, partial hospitalization, and intensive outpatient mental health and chemical dependency treatment.
 

How are preauthorization decisions made?

 

When considering preauthorization requests, we review all pertinent information available and we may communicate with your healthcare provider if additional clinical information is needed. Our preauthorization guidelines are based on current medical evidence, clinical criteria, medical necessity, and evidence-based criteria and are reviewed and updated as needed.

Can I call in a preauthorization request?

 

Requests must be received in writing from the requesting physician or healthcare provider. The preauthorization request form must be completed in full before we can begin the preauthorization process. We may require related chart notes and/or clinical information to make our best determination.

When can I expect my preauthorization to be completed?

 

We respond to preauthorization requests from healthcare providers within two business days.

How will I be notified of the decision?

 

As soon as a preauthorization determination is made, we mail notice of the decision to the member, physician, and facility or vendor. You and your provider can also check the status of your preauthorization request by Logging into InTouch, or by calling our Health Services Department at (888) 691-8209.

What should I do if I have a claim that wasn't approved for payment due to "Preauthorization Required?"

 

To have your claim reconsidered for coverage, have your provider's office submit a retrospective preauthorization request. The provider should include the fully completed preauthorization request form along with related chart notes and/or an operative report to support the request. We will process the request within 30 days of receipt.

Our Policy Prohibiting Financial Incentives

 

PacificSource Health Plans decisions regarding the provision of healthcare services are made under the following provisions:

  • Utilization management decision-making is based only on appropriateness of care and service, and the existence of coverage.
  • PacificSource does not specifically reward practitioners or other individuals for issuing denials of coverage.
  • Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization.

The nurses, physicians, other professional providers, and independent medical consultants who perform utilization review services for PacificSource are not compensated or given incentives based on their coverage review decisions. There are no financial incentives for such individuals that would encourage utilization review decisions that result in underutilization.

Health plan nurses, social workers, and physician reviewers are salaried employees of PacificSource, and contracted external physicians and other professional consultants are compensated on an hourly, per-case-reviewed, or population management basis, regardless of coverage determinations.

Claim Information

How to Send Us a Claim

 

Usually, your provider or pharmacy will submit claims on your behalf. If you need to fill a covered prescription or see an out-of-network provider for a covered service and the provider is not submitting the claim on your behalf, you can submit the claim to us. You will need to submit a copy of the provider’s itemized bill. The itemized bill needs to include:

  • Patient's name, 
  • Date of Service (mm/dd/yyyy) 
  • Procedure Code(s) 
  • Diagnosis Code(s) – ICD Format 
  • Healthcare professional’s full name, credentials, address, phone number, TIN, and NPI (if one is assigned) 
  • Total charge for each service rendered 
  • The date your prescription was filled or the service was provided 
  • The medication name, strength, and quantity dispensed

If the required information is not received, it may delay the processing of your claim.  

If your coverage is provided through your employer, please add your employer's name and group number (if known). If the treatment was for an accident, please include details. 

  • Mail your claim to PacificSource Health Plans, Claims Department, PO Box 7068, Springfield, OR 97475. 
  • Or fax:
    • medical and vision (541) 225-3632
    • pharmacy (541) 225-3665
    • dental (541) 225-3655.  
     

PacificSource encourages claims submission within 90 days of service. However, we will accept submitted claims for a period of one year from the date of service. Additionally, PacificSource will accept rebillings six months from the date the original claim was processed, not to exceed eighteen months from the date of service.  

More information filing claims can be found in your member handbook or policy.

Forms

Accident Report (Medical Service Questionnaire)

Claim Form - Dental

Prescription Drug Claim Form

Grace Periods and Claims Pending

 

There is a 30-day grace period for payment of each monthly premium, if the policyholder does not qualify for premium subsidy or tax credit. There is a three-month grace period for payment of each monthly premium, if the policyholder is receiving premium subsidy or tax credit. The policy will expire at the end of the grace period or after PacificSource has notified the policyholder in writing at the last known address that premium is past due.

Coverage and all claim liability end on the last day of the last month through which premiums were accepted by PacificSource. If PacificSource deposits funds remitted by the policyholder after the grace period, that action does not automatically constitute reinstatement of an expired policy. Enrollees who are receiving a subsidy will have coverage for all allowable claims for the first month of the three month grace period. Subsequent claims in the second and third month of the grace period will be pended until payment is received.

Ending Coverage and Claim Payments (Retroactive Claim Denial)

     

If you end (terminate) your PacificSource coverage, please let us know the end date as soon as possible. If your coverage is through an employer group plan, your employer will notify us. 

Claims are only paid for services or prescriptions you receive after your coverage starts and before your coverage ends. We process and pay claims according to your plan benefits while you have PacificSource coverage. 

How Claims Can Be Affected

In some cases, claims may be denied retroactively, even after you have obtained services from the healthcare provider. This can happen if your coverage ends and we haven’t received a coverage termination notice in time. For example, you might have changed employers or decided to end your PacificSource plan and stopped paying your premium. 

  • If we process and pay claims for services received after coverage ends, we will reprocess and deny the claim, and then ask for the paid amount to be refunded.
  • If your premium payment is late, we may hold claim payments until after we receive the premium. If your coverage ends, we will deny claims for services you received or prescriptions you filled after the coverage end date.

Note: If you had coverage under a different insurance company health plan at the time of the service, you or your doctor can submit the claim to that insurance company. If you didn’t have any coverage, you are responsible for paying the full cost of the service or prescription.

Claims Paid by Other Companies - Coordination of Benefits | Third Party Liability 

 

Coordination of Benefits

In some cases, a company other than PacificSource is responsible for paying your claim or paying it first (primary payer). If you or a dependent on your plan have coverage with another health plan, they may be considered the primary payer. This can be referred to as “double coverage.”  If another plan is primary, they would process and pay your claim first, then PacificSource would process the remainder of the claim according to your plan benefits.

Third Party Liability

If there is a motor vehicle accident, workers' compensation claim, or homeowners/premise claim, it may be the responsibility of a different company. These are often referred to as third party liability claims. Sometimes, we may need more information for your claim. We may ask you to fill out a Medical Service Questionnaire form (also called an accident report form) before we can finish processing the claim. 

Your Rights and Services

How to Voice a Complaint and Your Right of Appeal

 

Providing you with the best possible service is important to us. We understand that you may have questions or concerns about your benefits, eligibility, the quality of care you receive, or how we reached a claim determination or handled a claim. We try to answer your questions promptly and give you clear, accurate answers.

If you have a question, concern, or complaint, please contact our Customer Service Department. Many times our Customer Service staff can answer your question or resolve an issue to your satisfaction right away.

Customer Service staff is available 8:00 a.m. to 5:00 p.m., Monday through Friday: 

  • Oregon: (541) 684-5582 or (888) 977-9299
  • Idaho: (208) 333-1596 or (800) 688-5008
  • Montana: (406) 442-6589 or (877) 590-1596
  • TTY: (800) 735-2900
  • En Español: (541) 684-5456 or (800) 624-6052, ext. 1009 
  • Email: cs@pacificsource.com  

If we are not able to resolve the issue, you may file a formal grievance or appeal: 

  • Write to PacificSource, Attn: Grievance Review, PO Box 7068, Springfield, OR 97475-0068; 
  • Email lc@pacificsource.com, with "Grievance" as the subject; or 
  • Fax your message to (541) 225-3628.

More detailed information about our grievance and appeals process is provided in your member handbook or policy.

Your Right to Independent, External Appeals Review

 

If your dispute with PacificSource relates to an adverse benefit determination that a course or plan of treatment is not medically necessary; is experimental or investigational; is not an active course of treatment for purposes of continuity of care; or is not delivered in an appropriate healthcare setting and with the appropriate level of care, you or your authorized representative may request an external review by an independent review organization.

Your request for an independent review must be made within 180 days of the date of the second internal appeal response. External independent review is available at no cost to you, but is generally only available when coverage has been denied for the reasons stated above and only after all internal grievance levels are exhausted. The Plan will pay for any cost associated with the external independent review.

This information, along with additional information about appeal procedures, is available in your Member Handbook. To access your handbook, log into InTouch, go to the Benefits menu option, and select What’s Covered. You’ll find links to your handbook and more benefit details on this page.

How We Protect Your Personal Health Information

 

The privacy of your medical information is important to us. Learn more about our commitment to protect your personal health information in our Privacy Policy.

We also want you to know that as you are using our websites, information we may collect is used only to confirm your identity and answer your questions, provide you with information about your policy, or provide you with information about our services. We will not sell your information or provide information to marketing organizations. Learn more in our Website Privacy Statement.

Language Assistance

 

Language assistance is available by calling (541) 684-5456 or (800) 624-6052, ext. 1009 during our regular office hours of 8:00 a.m. to 5:00 p.m., Monday through Friday.

En Español: (541) 684-5456 or (800) 624-6052, ext. 1009

TDD/TTY Assistance

 

TDD/TTY service is available by calling (800) 735-2900 during our regular business hours of 8:00 a.m. to 5:00 p.m., Monday through Friday.

Your Rights and Responsibilities

 

PacificSource is committed to providing you with the highest level of service in the industry. By respecting your rights and clearly explaining your responsibilities under your health plan, we will promote effective healthcare.

This information is also provided in your member handbook or policy.

Your Rights as a Member:

  • You have a right to receive information about PacificSource, our services, our providers, and your rights and responsibilities. 
  • You have a right to expect clear explanations of your plan benefits and exclusions. 
  • You have a right to be treated with respect and dignity. 
  • You have a right to impartial access to healthcare without regard to race, religion, gender, national origin, or disability. 
  • You have a right to honest discussion of appropriate or medically necessary treatment options. You are entitled to discuss those options regardless of how much the treatment costs or if it is covered by this plan. 
  • You have a right to the confidential protection of your medical records and personal information. 
  • You have a right to voice complaints about PacificSource or the care you receive, and to appeal decisions you believe are wrong. 
  • You have a right to participate with your healthcare provider in decision-making regarding your care. 
  • You have a right to know why any tests, procedures, or treatments are performed and any risks involved. 
  • You have a right to refuse treatment and be informed of any possible medical consequences. 
  • You have a right to refuse to sign any consent form you do not fully understand, or cross out any part you do not want applied to your care. 
  • You have a right to change your mind about treatment you previously agreed to. 
  • You have a right to make recommendations regarding PacificSource Health Plans' member rights and responsibilities policy.

Your Responsibilities as a Member:

  • You are responsible for reading your benefit handbook or policy and all other communications from PacificSource, and for understanding your plan's benefits. You are responsible for contacting PacificSource Customer Service if anything is unclear to you. 
  • You are responsible for making sure your provider obtains preauthorization for any services that require it before you are treated. 
  • You are responsible for providing PacificSource with all the information required to provide benefits under your plan. 
  • You are responsible for giving your healthcare provider complete health information to help accurately diagnose and treat you. 
  • You are responsible for telling your providers you are covered by PacificSource and showing your ID card when you receive care. 
  • You are responsible for being on time for appointments, and calling your provider ahead of time if you need to cancel.
  • You are responsible for any fees the provider charges for late cancellations or 'no shows.' 
  • You are responsible for contacting PacificSource if you believe you are not receiving adequate care. 
  • You are responsible to supply information to the extent possible that PacificSource needs in order to administer your benefits or your medical providers need in order to provide care.
  • You are responsible to follow plans and instructions for care that you have agreed to with your doctors.
  • You are responsible for understanding your health problems and participating in developing mutually agreed upon goals, to the degree possible.
 

InTouch for Members

Be an Informed Healthcare Consumer

The healthcare system can sometimes seem like a maze of red tape, paperwork, and restrictions. To help you avoid confusion and get the care you need, we've put together some helpful suggestions.

Last updated 10/20/2017