Provider Manual—Commercial Plans

Filing Claims

Updates:  Last revised April 2018

Quick links:

  1. Eligibility and Benefits
  2. 1500 Health Insurance Claim Form Instructions
    2.1 CMS 1500 Form Implementation
  3. UB04 Instructions
  4. HCPCS Coding
  5. Electronic Medical Claims
  6. Explanation of Payment (EOP)
    6.1 How to Read Your EOP
  7. Prompt Pay Policy
  8. Accident Report Policy
    8.1 On-the-Job Injury
    8.2 Motor Vehicle Accident
    8.3 Third Party Liability
  9. Coordination of Benefits
    9.1 Group Health Insurance Coverage
    9.2 Individual Health Insurance Coverage
    9.3 Nondependent or Dependent
    9.4 Dependent Child Whose Parents Live Together
    9.5 Dependent Child of Divorced or Separated Parents
    9.6 Active/Inactive Employees
    9.7 COBRA or State Continuation Coverage
    9.8 Longer/Shorter Length of Coverage
  10. Document Imaging
  11. Overpayments
  12. Corrected Claims Submission



In health plans that include a prescription drug benefit, a comprehensive pharmacy services program is provided that includes drug list management, drug preauthorization, step therapy protocols, drug limitations, and a specialty drug program. 


2 Drug Preauthorization and Step Therapy Protocols

Certain drugs require preauthorization or step therapy for members with pharmacy or major medical prescription plans. This process includes an assessment of both your patient’s available benefits and medical indications for use. Be sure to preauthorize medication when required, to avoid your patient becoming responsible for the full cost of the medication.

We base our preauthorization and step therapy criteria on current medical evidence. We review and update them monthly to accommodate new drugs and changing recommendations. Our Quality Assurance, Utilization Management, Pharmacy and Therapeutics (QAUMPT) Committee must approve all criteria and formulary changes. The QAUMPT voting members consist entirely of providers and pharmacists from the communities we serve. Providers and members can access the current Preauthorization and Step Therapy Policies on our website at PacificSource.com/drug-list.

Requesting Preauthorization

The ordering physician or representative is required to contact our Pharmacy Services department for preauthorization. Pharmacy Services manages all drugs, whether covered by the pharmacy benefit or the medical benefit. Contact Pharmacy Services at (844) 877-4803, fax (541) 225-3665, or email



1 Eligibility and Benefits

PacificSource has a dedicated Customer Service department available to assist both you and your patients with questions related to claims status, benefits, and eligibility.

Customer Service Representatives are available Monday through Friday, 8:00 a.m. to 5:00 p.m. to answer your questions. Spanish-speaking representatives and translation services are also available.

Call PacificSource Customer Service for:

  • Claims status
  • Deductible, coinsurance, and/or co-payment information
  • Information regarding eligibility for PacificSource members
  • Benefit questions related to your patient’s coverage

You may reach Customer Service by phone at (541) 684-5582 or toll-free at (888) 977-9299, or by email at cs@pacificsource.com. The fax number is (541) 684-5264.

To better serve you, and to reduce on-hold wait times, we’ve added a new toll-free customer service phone line especially for commercial providers. Please make a note of the new number: (855) 896-5208. You can call this number to verify member benefits, check the status of referrals, or for general questions.



2 1500 Health Insurance Claim Form Instructions

PacificSource encourages providers to transmit claims electronically. (Please see Electronic Media Claims under Claims.) Electronic claims result in faster reimbursement, improved accuracy, and reduced costs associated with forms, envelopes, and postage. Paper claims are also accepted, preferably typed, on a 1500 Health Insurance Claim Form. The 1500 is the industry standard for submission of paper claims and is required for optical scanning. Effective April 1, 2014, the New CMS 1500 (Rev 02/12) is required for billing any new or corrected claims to PacificSource.

If you do not wish to file electronically, the 1500 claim form is available in the For Providers section of our website, PacificSource.com (click on Forms). You may also obtain the form by contacting our Provider Network department by phone (541) 684-5580, or toll-free at (800) 624-6052, ext. 2580, or by email at providernet@pacificsource.com.

The preparation of the form in its entirety is encouraged. This will eliminate the need for PacificSource to request additional information, and will enable us to process the bill quickly.

A separate billing form is required for each patient and must be legible. General and specific instructions are listed for assistance in completing the claim form correctly.

Printed in the upper left-hand corner of the 1500 claim form are the name and address of the insurance carrier.

Item 1: Type of Insurance: Mark “Group Health Plan” or “Other” for PacificSource claims

1a: Insured’s ID Number.

Item 2: Patient’s Name: Must be the patient’s full legal name—do not use nicknames.

Item 3: Patient’s Date of Birth and Sex: Must be included to correctly identify the member.

Item 4: Insured’s Name: Must be the name of the employee or policyholder.

Item 5: Patient’s complete address and phone number.

Item 6: Patient Relationship to Insured.

Item 7: Insured’s Address.

Item 8: Patient Status.

Item 9a-d: Other Health Insurance Coverage. It is very important to identify other group coverage for accurate coordination of benefits. If the patient has no other group coverage, please enter “NONE.”

Item 10a-c: Is Patient’s Condition Related To: Coverage for employment, auto, or other accident-related claims takes precedence over PacificSource coverage.

Item 11a-d: Insured’s Policy, Group or FECA Number; Insured’s DOB; Insured’s Name; Other Health Plan.

All members over 16 years of age are issued an identification card, which providers should always ask to see. Children under age 16 will be listed on the parent or guardian’s card.

Item 12: Patient’s Signature and Date.

Item 13: Insured’s Signature.

Item 14: The date of first symptom for current illness, injury, or last menstrual period (LMP) for pregnancy.

Item 15: The date the patient first had the same or a similar illness.

Item 16: Dates Patient Unable to Work in Current Occupation.

Item 17: Name of Referring Physician (if applicable).

17a: ID Number of Referring Physician, i.e., UPIN, Medicaid, Medicare, etc.

17b: NPI.

Item 18: Hospitalization dates related to current services.

Item 20: Outside Lab: Complete this item when billing for purchased services.

Item 21: Enter the patient’s diagnosis/condition. ICD Indicator must be filled in or claims will reject. List up to 12 diagnostic codes. Relate lines A–L to the lines of service in 24E by line number. Use the highest level of specificity. Do not provide narrative description in this item.

The use of V Codes is encouraged to classify factors influencing health status and contact with health services. V Codes must not be used as the primary diagnosis.

Item 22: Medicaid Resubmission: Only used for Medicaid Claims.

Item 23: Prior Authorization Number.

Item 24: Supplemental Information: The top area of the six service lines is shaded. Use this area for reporting supplemental information. It is not intended to allow the billing of 12 lines of service.

24a: Date(s) of Service: Indicate the month, day, and year the service(s) was provided. Grouping services refers to a charge for a series of identical services without listing each date of service.

24b: Place of Service: Indicate if the service was rendered in office, emergency room, hospital inpatient care, etc.

24c: EMG: Not required by PacificSource.

24d: Procedures, Services, or Supplies: Enter the applicable CPT or HCPCS code(s) and modifier(s) from the appropriate code set in effect on the date of service. This item accommodates the entry of up to four two-digit modifiers. The specific procedure code(s) must be shown without a narrative description. HCPCS codes may be used to describe services, procedures, and supplies not covered by CPT coding.

24e: Diagnosis Pointer: Enter the diagnosis code reference number (pointer) as shown in Item Number 21.

24f: Charges: Enter the charge for each listed service. A copy of an operative report on all unusual or complicated procedures should be included.

24g: Days or Units.

24h: EPSDT/Family Plan.

24i: ID Qualifier: Enter the qualifier that identifies a non-NPI number in the shaded area.

24j: Rendering Provider ID #: The individual rendering the service is reported in 24J. Enter the non-NPI ID number in the shaded area, enter the NPI number in the unshaded area.

Item 25: Federal Tax ID Number: Enter the number used to report income for tax purposes.

Item 26: Patient’s Account Number: PacificSource will enter this number (if provided) in the claim record to be printed on EOP.

Item 27: Accept Assignment.

Item 28: Total charges for services.

Item 29: Amount Paid.

Item 30: Balance Due.

Item 31: PacificSource requires the provider that rendered the service or the supervising provider be indicated in box 31 on the CMS 1500 claim form or the appropriate field on an electronic claim. It is the responsibility of the supervising provider to ensure that the integrity of this policy is being adhered to at all times.

Please remember that PacificSource requires all providers rendering services to be individually credentialed before they can be considered a participating under the provider contract. This includes a nurse practitioner, physician assistant or other mid-level providers.

Item 32: Service Facility Location Information: Enter the name, address, city, state, and zip code of the location where the services were rendered. Providers of service (namely physicians) must identify the supplier’s name, address, ZIP code, and NPI number when billing for purchased diagnostic tests. When more then one supplier is used, a separate 1500 Claim Form should be used to bill for each supplier.

32a: NPI number.

32b: Other ID number.

Item 33: Billing Provider Info & Phone #: Enter the provider’s or supplier’s billing name, address, zip code, and phone number. The phone number is to be entered in the area to the right of the item title.

33a: NPI number.

33b: Other ID number.

Common reasons for returned or not approved claims:

  • Print is too light
  • Patient cannot be identified as a PacificSource member
  • More than one physician, provider, or supplier billing on one claim
  • Claims not submitted on the most recent 1500 Health Insurance Claim Form
  • Incomplete or inaccurate coding

Please submit claims to the following address:

PacificSource Health Plans
PO Box 7068
Springfield, OR 97475

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. Initial bills, rebills, and adjustments that are received after this stated period of time will not be payable by PacificSource or by our member.

PacificSource strives to make the claims process as efficient as possible. We ask that when you submit a corrected claim that it is submitted with our Corrected Claim Form and chart notes, if applicable. This form will help us to more easily assess the reason for the change, resulting in a faster turnaround time. Please do not submit corrected claims without the Corrected Claim Form as these are seen as duplicate submissions and will be denied. At this time we are unable to accept corrected claims in electronic format. You can find the Corrected Claim Form in Providers > Forms and Materials.

If a claim is not approved, and you believe it is an error, simply resubmit the claims and an explanation to PacificSource for reconsideration, providing time limitations are not exceeded. PacificSource will review the case to determine whether the claim is eligible for payment under the terms of the contract. You will be notified in writing of the determination.

Note: Multiple resubmissions will calculate from the original date the claim was processed.

2.1 CMS 1500 Form Implementation

In preparation for ICD-10, the CMS 1500 claim form has been updated to accommodate the new code set. Please be aware of the following time line:

  • January 1–March 31, 2014: You can use either the current (08/05) or the revised (02/12) 1500 claim form. Health plans, clearinghouses, and billing vendors will accept and process either version of the form.
  • Beginning April 1, 2014: The current (08/05) 1500 claim form will be discontinued; only the revised (02/12) 1500 claim form is to be used. All rebilling of claims will be on the revised (02/12) 1500 claim form from this date forward, even though earlier submissions may have been on the current (08/05) 1500 claim form.



3 UB04 Instructions

The UB04 claim form is available in the For Providers > Forms section of our website. You may also obtain the form by contacting our Provider Network department by phone (541) 684-5580, or toll-free at (800) 624-6052, ext. 2580, or by email at providernet@pacificsource.com.

The preparation of the form in its entirety is encouraged. This will eliminate the need for PacificSource to request additional information, and will enable us to process the bill quickly. A separate billing form is required for each patient and must be legible. General and specific instructions are listed for assistance in completing the claim form correctly.

FL 1: Provider Name, Address, and Telephone Number. Required

FL 2: Pay-to Name, Address, and Secondary Identification Fields. Situational. Required when the pay-to name and address information is different than the Billing Provider information in FL1.

FL 3a: Patient Control Number. Required. The patient’s unique alphanumeric control number assigned by the provider to facilitate retrieval of individual financial records and posting payment may be shown if the provider assigns one and needs it for association and reference purposes.

FL 3b: Medical/Health Record Number. Situational. The number assigned to the patient’s medical/health record by the provider (not FL3a).

FL 4: Type of Bill, 4-digit alphanumeric code.

FL 5: Federal Tax ID Number. Required.

FL 6: Statement Covers Period (From—Through). Required. Enter beginning and ending dates of the period included on this bill.

FL 7: Not used.

FL 8a–b: Patient’s Name. Required. Enter the patient’s last name, first name, middle initial, and patient ID (if different than the subscriber/insured’s ID).

FL 9a–e: Patient’s Address. Required. Enter the patient’s full mailing address, including street number and name, post office box number or RFD, city, state, and ZIP code.

FL 10: Patient’s Birth Date. Required.

FL 11: Patient’s Sex. Required.

FL 12: Admission Date. Required for Inpatient and Home Health.

FL 13: Admission Hour.

FL 14: Type of Admission/Visit. Required.

FL 15: Source of Admission. Required.

FL 16: Discharge Hour.

FL 17: Patient Status. Required.

FL 18–28: Condition Codes. Situational.

FL 29: Accident State.

FL 30: Not used.

FL 31–34: Occurrence Codes and Dates. Situational.

FL 35–36: Occurrence Span Code and Dates. Required for Inpatient.

FL 37: Not used.

FL 38: Responsible Party Name and Address.

FL 39–41: Value Codes and Amounts. Required.

FL 42: Revenue Code. Required.

FL 43: Revenue Description.

FL 44: HCPCS/Rates/HIPPS Rate Codes. Required.

FL 45: Service Date. Required.

FL 46: Units of Service. Required.

FL 47: Total Charges. Not Applicable for Electronic Billers. Required

FL 48: Noncovered Charges. Required

FL 49: Not used.

FL 50a–c: Payer Identification. Required

FL 51: Health Plan ID

a: Required.

b: Situational.

c: Situational.

FL 52a–c: Release of Information Certification Indicator. Required.

FL 53a–c: Assignment of Benefits Certification Indicator.

FL 54a–c: Prior Payments. Situational.

FL 55a–c: Estimated Amount Due From Patient.

FL 57: Other Provider ID. Situational.

FL 58a–c: Insured’s Name. Required.

FL 59a–c: Patient’s Relationship to Insured. Required.

FL 60a–c: Insured’s Unique ID. Required.

FL 61a–c: Insurance Group Name. Situational (required if known).

FL 62a–c: Insurance Group Number. Situational (required if known)

FL 63: Treatment Authorization Code. Situational.

FL 64: Document Control Number. Situational.

FL 65: Employer Name. Situational.

FL 66: Diagnosis and Procedure code Qualifier (ICD Version Indicator). Required.

FL 67: Principal Diagnosis Code. Required.

FL 67a–q: Other Diagnosis Codes. Inpatient Required.

FL 68: Not used.

FL 69: Admitting Diagnosis. Required.

FL 70a–c: Patient’s Reason for Visit. Situational.

FL 71: DRG

FL 72: External Cause of Injury Codes.

FL 73: Not used.

FL 74: Principal Procedure Code and Date. Situational.

FL 74a–e: Other Procedure Codes and Dates. Situational.

FL 75: Not used.

FL 76: Attending Provider Name and Identifiers (including NPI). Situational.

FL 77: Operating Provider Name and Identifiers (including NPIs).

FL 78–79: Other Provider Name and Identifiers (including NPIs.)

FL 80: Remarks. Situational.

FL 81: Code—Code Field. Situational.

Common reasons for returned or not approved claims:

  • Print is too light
  • Patient cannot be identified as a PacificSource member
  • More than one physician, provider, or supplier billing on one claim
  • Claims not submitted on the most recent 1500 Insurance Claim Form or UB04 Form
  • Incomplete or inaccurate coding

Please submit claims to the following address:

PacificSource Health Plans
PO Box 7068
Springfield, OR 97475-0068

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. Claims submitted after the allowable one-year time limit will be processed and not approved. Exceptions will be considered on a case-by-case basis.

If a claim is not approved and you believe it is an error, simply resubmit the claim with an explanation to PacificSource for reconsideration. PacificSource will review the case to determine whether the claim is eligible for payment under the terms of the contract. You will be notified in writing of the determination.



4 HCPCS Coding

PacificSource requires current HCPCS coding for durable medical equipment, supplies, and office medication whenever possible. Utilization of this coding system is designed to promote uniform medical services reporting and statistical data collection. The HCPCS Level II code book is prepared for use with Current Procedural Technology (CPT) codes published by the federal government and is the standard for coding these services.

The Health Care Financing Administration (HCFA) updates HCPCS codes annually. HCFA created this series of codes to supplement CPT coding, which does not include coding for nonphysician procedures, such as durable medical equipment and specific supplies. In addition, more specific codes were created for the administration of injectable drugs. If a compatible CPT code is available, always use the CPT code instead of the HCPCS code.

Durable Medical Equipment (DME) and Supplies, Including Orthotics and Prosthetics

  • Use the appropriate E, K, or L code to describe durable medical equipment, supplies, orthotics, or prosthetics.
  • Durable Medical equipment over $800 requires preauthorization. Please see the Medical Management section, 6.3.3—Services Requiring Preauthorization.
  • If there is no code, use the appropriate unlisted procedure code and include a description of the item.
  • Drug Administration
  • Use the appropriate J code to describe drugs administered, including injectable, oral, and chemotherapy drugs.
  • Look closely at the code description for unit or dosage information. If more than the designated unit or dosage amount is used, enter the multiple value in the “Number of Service” area on the CMS 1500 form.
  • If there is no code, use the appropriate unlisted procedure code and include a description of the item.
  • Sterile Tray

Use HCPCS code A4550. Please see Billing Guidelines section, 11.2—Office Surgery, for billing instructions for additional allowance when using office surgery suite.

Special Report

A special report is required when a new, unusual, or variable procedure is provided.

Unlisted Procedures

Use an unlisted procedure code only when the service or supply is not otherwise classified. Claims coded with miscellaneous HCPCS codes may be subject to review by Health Services, and may require a report.

Modifiers

Under certain situations, a code may require a modifier to indicate that the procedure has been altered by a specific circumstance. In some instances, modified procedures may be subject to review by Health Services. A special report may be required to clarify the use of the modifier.


 


5 Electronic Medical Claims

PacificSource is proactive in moving claims electronically, and we encourage providers to consider electronic billing opportunities.

Some of the benefits providers can realize by transmitting claims electronically are:

  • Faster reimbursement. By eliminating the time it takes for mailing, internal routing, and data entry, claims are in our system much faster, and are in line for payment sooner.
  • Reduced costs. Electronic billing saves providers money by eliminating the cost of forms, postage and staff time.
  • Accuracy. Electronic claims transmittal helps prevent errors and omission of required information, resulting in accurate claims processing.

These benefits can be translated into increased efficiency and productivity, resulting in improved patient relations. Your office will realize greater efficiency through a more streamlined process.

For a list of clearinghouses, visit our website at PacificSource.com, or contact your Provider Service Representative by phone at (541) 686-1242 or toll-free at (800) 624-6052, or by email providernet@pacificsource.com.

For information on connecting to an electronic clearinghouse, please contact our Information Technology department by phone at (541) 225-3743 or toll-free at (800) 624-6052, ext. 3743, or by email at edisupport@pacificsource.com.



6 Explanation of Payment (EOP)

6.1 How to Read Your EOP

The PacificSource Explanation of Payment (EOP) is a computer printout sheet that is mailed, along with payment, to physicians and providers on each scheduled payment date. The following information explains how to interpret the PacificSource EOP:

Patient Number: The provider’s name and the account number for each patient is listed in the first column of the EOP.

Patient Name and Claim Number: The patient’s name and the PacificSource claim number are listed in next two columns of the EOP.

The payment information on the following page is listed under the appropriate headings in the last nine columns of the EOP: Date of Service, Procedure Number, Billed Amount, Amount Applied to Deductible (if applicable), Patient Balance Amount (patient responsibility), Withhold Amount (if applicable), Write-off (if applicable), Paid Amount, and Reason Code.

Explanation of Payment Codes: This information appears at the end of the disbursement section. If further claim status clarification is needed, please contact Customer Service at (541) 684-5582 or toll-free at (888) 977-9299, or by email at cs@pacificsource.com.

Auto Recovery Example #1

  1. Claim A was paid at $116.06 when originally processed.
  2. Claim A has now been adjusted to show a zero payment due to member ineligibility.
  3. This creates an overpayment of $116.06 on claim A.
  4. Claim B is paying $64.68.
  5. The overpayment on claim A is being deducted from the payment on claim B. This leaves an outstanding overpayment of $51.38 for claim A. This amount will be recovered on the next Explanation of Payment.

Auto-Recovery-Example-1-01-1

Auto Recovery Example #2

  1. Claim C was paid at $212.29 when originally processed.
  2. Claim C has now been adjusted to show a corrected payment of $156.10 due to a corrected claim received.
  3. This creates an overpayment of $56.19 on claim C.
  4. Claim D is paying $1,904.06.
  5. The remaining overpayment on Claim A ($51.38) and the new overpayment on claim C are being deducted from the payment on Claim D.
  6. This results in a net payment on the Explanation of Payment of $1,796.49.

Auto-Recovery-Example-2-01-1



7 Prompt Pay Policy

  • Effective January 1, 2002, PacificSource will pay or not approve a clean claim not later than 30 days after the date we receive the claim.
  • We will begin counting the number of days either on the day PacificSource actually receives the claim, or on the day our representative (who performs claims handling, including pricing, on our behalf) receives the claim—whichever day comes first.
  • A clean claim is a claim that has no defect, impropriety, lack of any required substantiating documentation, or particular circumstance requiring special treatment that prevents timely payment.
  • If additional information is necessary in order to process a claim, we will notify the provider and the enrollee in writing of the delay, and provide an explanation of the additional information required. We will process the claim not later than 30 days after the date we receive the additional information.
    • Provider contracts shall not include any provisions that are contrary to this policy.
    • PacificSource has an established method for informing providers of the necessary information to correctly submit a claim, and will make that information easily accessible.
  • If we fail to pay a claim within 30 days of receipt when no additional information is needed, or within 30 days from the receipt of the additional information requested, we will pay simple interest of 12 percent per annum on the unpaid amount of the claim that is due. The interest will accrue from the date after the payment was due until the claim is paid. Interest payments will be limited to those required by state or federal law.
  • If the interest is $2.01 or more, the interest will be paid with payment of the claim (we do not pay interest of $2.00 or less).



8 Accident Report Policy

Accident information is essential for determining which insurance company has primary responsibility for a claim. There are three main situations that may arise where another insurance carrier could be liable for benefits.

8.1 On-the-job Injury

PacificSource policies generally are not responsible for any services or supplies for sickness or injury arising out of, or in the course of, employment for wages or profit where state law requires employers to provide their employees with some type of Workers’ Compensation coverage for job related medical bills. This may include situations where a business or employer can elect not to provide such coverage. Determination of actual legal responsibility can delay payments. Depending on the state where the policy was issued, the member may be eligible for interim benefits prior to the determination of actual legal responsibility. Please contact PacificSource Third Party Recovery team for more information.

8.2 Motor Vehicle Accident

Any expense which results from a motor vehicle injury and which is payable by a motor vehicle insurance policy without regard to liability will not be a covered expense under a PacificSource policy. This includes, for example, any injury involving an auto including getting into, out of or working on a car.

In Oregon, these types of injuries fall under Personal Injury Protection, Oregon’s No Fault Auto Coverage.

In Idaho, health insurance is coordinated with auto insurance under Idaho Coordination of Benefits (COB) rules.

Until it is determined who is legally responsible for an injury, PacificSource may require a subrogation agreement to be signed before we can process any claims related to the injury. Upon receipt of this signed agreement, PacificSource is then able to process claims according to the contract benefits. If it is a payable claim through the third party, PacificSource is then reimbursed on the amount paid on the case.

10.8.3 Third Party Liability

An employee or an eligible dependent may have a legal right to recover the costs of his or her healthcare from a third party that may be responsible for the illness or injury. For example, if a person was injured in a business, the owner may be responsible for the healthcare expenses arising out of the injury under the premise’s medical coverage. As another example, a third party’s homeowners insurance may be responsible for an injury to someone outside his or her immediate family when an injury is sustained on the homeowner’s property.

Depending on the terms of the member’s policy, PacificSource may extend benefits while the member is pursuing recovery from the responsible party. Claims would be processed at contract benefits and PacificSource would expect to be reimbursed for any claims paid once settlement is reached.



9 Coordination of Benefits

9.1 Group Health Insurance Coverage

Usually, group health insurance coverage, in Idaho, Montana, Oregon, and Washington, follows the COB order of benefits indicated below. Self-insured employer groups may not be subject to state insurance regulations and may follow different COB rules. If that is the case, a self-insured and a fully insured Plan may coordinate benefits differently than stated below.

9.2 Individual Health Insurance Coverage

In Oregon, the term “Plan” does not include individual or short term health insurance policies. Generally, individual coverage will only pay the amount not covered by any other coverage. This is generally referred to as “nonduplication of benefits” (not COB).

9.3 Nondependent or Dependent

The Plan that covers the person other than as a dependent (e.g., employee, member, subscriber, or retiree) is primary.

9.4 Dependent Child Whose Parents Live Together

For a dependent child whose parents are married or living together, whether or not they have ever been married:

The Plan of the parent whose birthday falls earlier in the calendar year is primary.

If both parents have the same birthday, the Plan that has covered the parent longer is primary.

9.5 Dependent Child of Divorced or Separated Parents

For a child whose parents are divorced or separated or not living together, whether or not they have ever been married:

If a court decree states one parent is responsible for the child’s healthcare expense, and the Plan is aware of the decree, the Plan of that parent is primary.

If a court decree states that both parents are responsible for the child’s healthcare expense, or assigns joint custody without specifying responsibility, the rule for “Dependent Child Whose Parent Live Together” (above) apply.

If there is not court decree allocating responsibility for the child’s healthcare expense, the Plan of the parent that has custody of the child is primary; the Plan of the spouse of the custodial parent is second; the Plan of the noncustodial parent is third; and the Plan of the spouse of the noncustodial parent is fourth.

9.6 Active/Inactive Employees

The Plan covering the person as an active employee, or dependent of an active employee when none of the above rules apply, is primary.

The Plan covering the person as an inactive employee, (e.g., retired or laid-off employee), or dependent of an inactive employee when none of the above rules apply, is secondary.

9.7 COBRA or State Continuation Coverage

The Plan covering a person as an employee, member, subscriber, or retiree or the dependent of an employee, member, subscriber, or retiree is primary to a Plan covering the person as a COBRA or state continuation beneficiary.

9.8 Longer/Shorter Length of Coverage

If none of the above rules apply, such as when a self-insured and fully insured Plan’s COB provisions do not agree, generally the Plan that covered the person the longest will be primary.



10 Document Imaging

Imaging technology (scanning paper and electronically storing and displaying an image of the paper on screen) has been utilized in business for many years. The advent of a computer network within PacificSource and the decreased price of hardware has made imaging technology a realistic and efficient method of storing paper.

PacificSource began the transition to electronic imaging in March 1998. The first application involves claims entry and retrieval. Claims are sorted into CMS 1500, UB-92, dental and miscellaneous categories and shipped to a service bureau in Portland. The bureau scans the documents, stores the images onto high-volume media and ships them back to PacificSource.

Guidelines for submitting claims for imaging:

  • Use the CMS 1500 form
  • Printing should be dark and clear
  • 10- to 12-point type
  • Black or blue print
  • No discoloration or smudges
  • Information aligned in appropriate box
  • Only required claim form information
  • Only one code per service line
  • Circle specific pertinent information
  • Diagnosis appropriate to date of service in box 21(1)
  • Box 24(E) diagnosis corresponds to box 21(1)
  • Block 25—Federal Tax Identification number
  • Block 33—PIN (assigned PacificSource provider/payee number)

The above guidelines will help ensure the timely processing and payment of claims.



11 Overpayments

In response to Oregon Senate Bill 508, PacificSource has adapted a new refund policy that will apply to all providers regardless of geographic location or network status. This policy will over-ride any contract language. Our refund policy is as follows:

  • PacificSource will send the provider an initial refund request.
  • 30 days from the initial request: If we have not received a refund, or the provider has not contested the refund within this time frame, we will send a reminder (second refund request).
  • 60 days after the initial request: If we have still not received the refund, the overpayment will be auto-recovered on the next scheduled payment. Please see EOP examples on the previous pages.

To contest a refund, PacificSource requires the use of our Contested Refund Form, which is available at 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 but not limited to:

  • A new primary EOP when coordination of benefits is involved
  • Chart notes that support the original payment



12 Corrected Claims Submission

PacificSource strives to make the claims process as efficient as possible. We ask that when you submit a corrected claim that it is submitted with our corrected claims form and chart notes if applicable. This form will help us to more easily assess the reason for the change, resulting in a speedier turnaround time. Please do not submit corrected claims without the corrected claims form as these are seen as duplicate submissions and will be denied. At this time we are unable to accept corrected claims in electronic format. You can find the corrected claims form in the For Providers > Forms section of our website. 

 

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Last updated 1/22/2019