Provider Information and Resource Center
Who to Contact for Help
When you have questions or need assistance, we're here to help you get the answers you need. The categories below will help you connect with our Provider Network teams. Our offices are open 8:00 a.m. to 5:00 p.m., Monday through Friday. Download our print-friendly contact list.
Please contact our Provider Service Department to:
- Request provider education
- Request on-site visits
- Receive assistance with training or trouble-shooting InTouch for Providers
- Request allowed amounts
- Ask questions about claims
- Research claim denial
- Ask questions about the codebook
- Ask questions about 835/EFT
Web: View Our Provider Service Staff Directory
Email:
Phone:
- Idaho and Montana: (541) 246-1459, or toll-free (855) 247-7579
- Oregon: (541) 246-1457, or toll-free (855) 247-7575
Fax:
- Idaho: (208) 433-4634
- Montana: (406) 422-1010
- Oregon: (541) 225-3643
Please contact our Provider Credentialing Department if you have general credentialing questions, or you would like to check the status of credentialing or recredentialing.
IPN Contact Information (Idaho Providers)
Please contact our Provider Contracting Department if you have general contract questions, would like to request a new contract, check the status of a contract, or renegotiate rates.
Please contact our Provider Operations Department to:
- Check provider participation status
- Verify Medicare or Medicaid participation
- Add, delete, or correct provider demographics
- Add or delete a provider from your group
- Update a W9 or 1099
- Update a roster or IPA
Contacting Provider Operations:
Where to Find Information
Through InTouch for Providers, you can access claims, request and check the status of preauthorization, and view member benefit information, 24/7. The site is available through OneHealthPort, a web portal that provides access to local, secure health plan websites and other provider services with a single user ID and password.
Learn more about InTouch and OneHealthPort, how to register, and more >
PacificSource Community Health Plans (PacificSource Medicare) has prepared a Provider Manual: PacificSource Medicare for contracted providers as a reference tool for important information about the role of the provider and office staff in the delivery of healthcare to our members and your patients.
In addition to using the Provider Manual, you may also visit Medicare.PacificSource.com for other tools, such as provider directories, formularies, and plan documents.
PacificSource Community Health Plans (PacificSource Community Solutions) created the Provider Manual: PacificSource Community Solutions as a reference tool to assist providers when working with Medicaid patients. This manual provides critical information regarding provider and plan responsibilities.
In addition to using the Provider Manual, you may also visit CommunitySolutions.PacificSource.com for other tools, such as provider directories, formularies, and plan documents.
Commercial Physician and Provider Manual
Provider Bulletin Quarterly Newsletter
The Provider Bulletin is produced quarterly and distributed via email. This newsletter offers information about what's happening with PacificSource and the healthcare industry, as well as specific updates for commercial, Medicare, and Medicaid plans and patients.
If you're not already signed up to receive the Provider Bulletin newsletter, sign up here.
Common Questions
What's the policy regarding referrals?
As of January 1, 2016, members no longer need their primary physician's referral through PacificSource to see a specialist. This includes Medicare Advantage plan members. There are a few exceptions:
- Prime plans, which have the primary care provider referral requirement
- Medicare MyCare (in the Portland area), which have the primary care provider referral requirement
- Specialists who require a referral prior to a visit or treatment.
While this policy allows our members greater flexibility and choice, we recognize that primary physicians play a vital role in the health of our members. We will continue to encourage all members to select and seek care from their primary care provider, regardless of referral requirements.
How can I get paid quickly?
Here are two simple things you can do to expedite claims payments:
- Be sure the billing address you entered is where you would like the payment to be sent.
- In the Service Location field, enter the address where the provider performed the service.
Can I check benefits online?
Yes! With InTouch for Providers, you can verify eligibility and check claims status, explanations of payment, preauthorizations, and much more—all online!
Note: InTouch access is through OneHealthPort. If you are already registered with OneHealthPort, you do not need to re-register. For more information, visit PacificSource.com/AboutProviderInTouch.
Patient Care
We advise our members to show their ID card at their doctor's office or pharmacy so that you have the information you need to submit claims on their behalf.
Temporary ID Cards
If your patient is a new PacificSource member or is a current member needing a new card, they can print a temporary ID card. They will need their plan information to fill in the required fields and generate a temporary card.
Temporary ID cards will only be available to your patients with PacificSource coverage if their plan is active. If their plan starts on a future date (for example, the first of next month), they will need to wait until that date to print a temporary ID card.
Requesting Replacement ID Cards
Patients with PacificSource coverage should call our Customer Service Department or visit InTouch for Members to request a new ID card.
Online Directory Requirements
As of January 1, 2016, the Centers for Medicare and Medicaid Services (CMS) requires all Medicare Advantage Organizations and health insurance carriers to conduct a monthly outreach to all contracted providers to verify provider accessibility for Medicare Advantage or commercial members.
Please be aware, you will receive requests from PacificSource each month, as well as from other payers, to verify the information on file for the providers in your office or facility. We ask that you review this information and reply as quickly as possible, as CMS requires these updates and corrections be made to our online directory in "real time."
We realize this may be burdensome on your office staff, but please understand these are requirements established by CMS.
If you have any questions or comments, please feel free to contact your Provider Service Representative.
As of January 1, 2016, members no longer need their primary physician's referral through PacificSource to see a specialist. This includes Medicare Advantage plan members. There are a few exceptions:
- Prime plans, which have the primary care provider referral requirement
- Medicare MyCare (in the Portland area), which have the primary care provider referral requirement
- Specialists who require a referral prior to a visit or treatment.
While this policy allows our members greater flexibility and choice, we recognize that primary physicians play a vital role in the health of our members. We will continue to encourage all members to select and seek care from their primary care provider, regardless of referral requirements.
Information about PacificSource Health Plans' pharmacy program is available at PacificSource.com/provider/drug-news. There, you can find information regarding:
- PacificSource drug lists, including restrictions and preferences, as well as regular updates to the lists
- How to use the pharmaceutical management procedures, such as preauthorization requirements
- Explanation of limits or quotas
- How to provide information to support an exception (preauthorization process)
- Generic substitution, therapeutic interchange, and step-therapy protocols
Member Rights and Responsibilities
PacificSource strives to provide our customers with the highest level of service in the industry. This level of service will be measurable and documented.
PacificSource Health Plans Statement of Principles
In keeping with our commitment to provide the highest quality healthcare service to our members, PacificSource Health Plans acknowledges the importance of accountability and cooperation. We have ensured a relationship of mutual respect among our members, practitioners, and the health plan by the creation of a partnership of the three parties. Recognition of certain rights and responsibilities of each of the partners is fundamental to this partnership.
PacificSource Health Plans assures our members of the following:
- Members have a right to receive information about PacificSource, our services, our providers, and their rights and responsibilities.
- Members have a right to expect clear explanations of their plan benefits and exclusions.
- Members have a right to be treated with respect and dignity.
- Members have a right to impartial access to healthcare without regard to race, religion, gender, national origin, or disability.
- Members have a right to honest discussion of appropriate or medically necessary treatment options. Members are entitled to discuss those options regardless of how much the treatment costs or if it is covered by their plan.
- Members have a right to the confidential protection of their medical records and personal information.
- Members have a right to voice complaints about PacificSource or the care they receive, and to appeal decisions they believe are wrong.
- Members have a right to participate with their healthcare provider in decision-making regarding their care.
- Members have a right to know why any tests, procedures, or treatments are performed and any risks involved.
- Members have a right to refuse treatment and be informed of any possible medical consequences.
- Members have a right to refuse to sign any consent form they do not fully understand, or cross out any part they do not want applied to their care.
- Members have a right to change their mind about treatment they previously agreed to.
- Members have a right to make recommendations regarding PacificSource Health Plans' member rights and responsibility policy.
As partners with PacificSource, members are responsible for:
- Reading their policy or handbook and all other communications from PacificSource, and for understanding their policy's benefits. Members are responsible for contacting PacificSource Customer Service if anything is unclear to them.
- Making sure their provider obtains benefit verification for any services that require it before they are treated.
- Providing PacificSource with all the information required to provide benefits under their plan.
- Giving their healthcare provider complete health information to help accurately diagnose and treat them.
- Telling their providers they are covered by PacificSource and showing their ID card when receiving care.
- Being on time for appointments, and calling their provider ahead of time if they need to cancel.
- Any fees the provider charges for late cancellations or "no shows."
- Contacting PacificSource if they believe they are not receiving adequate care.
- Supplying information to the extent possible that PacificSource needs to administer their benefits or their provider needs in order to provide care.
- Following the plans or instructions for care that the member has agreed to with their doctors.
- Understanding their health problems and participating in developing mutually agreed upon goals, to the degree possible.
You can also find this information on our Member Rights and Responsibilities, please reference our Provider Manual, Section 9, at Pacificsource.com/provider/provider-manual.
Case Management and Utilization Management
Case Management Support and Referrals for Members with Complex or Chronic Conditions
Case management is a service available to all PacificSource members who have complex or chronic medical conditions and require support to manage their healthcare needs. It is a service aimed at improving health outcomes and quality of life and reducing healthcare costs.
Our case managers are registered nurses and licensed mental health professionals with extensive clinical experience. They work collaboratively with members and their healthcare providers to provide improved clinical, humanistic, and financial outcomes for members.
Case management can be of great help to members experiencing a wide range of complex medical issues with extensive care needs. If you would like to refer a patient to case management, please contact our Health Services Department at (888) 691-8209.
Condition Support Program Information
Utilization Management (UM): Availability and Criteria for Obtaining UM
Access to Medical Necessity Criteria
Our on-staff physicians, registered nurses, and licensed mental health professionals apply a variety of criteria to assist in the determination of medical necessity. These criteria sources include MCG (Milliman Care Guidelines), ASAM (American Society of Addiction Medicine) Guidelines for Substance Use Disorders, PacificSource medical criteria and guidelines, and PacificSource pharmacy criteria. When standardized criteria or guidelines are not available, our reviewers utilize evidence-based data and expert professional review to determine coverage. Specific medical necessity criteria and guidelines are available to our participating physicians and providers upon request by calling the PacificSource Health Services Department at (541) 684-5584, or toll-free at (888) 691-8209, or by fax: (541) 225-3625.
Access to Information about the UM Process
PacificSource Health Plans Health Services Department staff members are available during normal business hours (Monday-Friday, 8:00 a.m. to 5:00 p.m., PT) to discuss specific utilization management requirements, procedures, or the UM process. You may contact the Health Services Department by phone at (541) 684-5584 or toll free at (888) 691-8209 or by fax: (541) 225-3625.
If electronic communication is preferred, you may contact the Health Services Department via the "Contact Us" page of PacificSource.com using a secure email form.
After normal business hours, incoming calls to Health Services are forwarded to voice mail. A staff member will return the call the next business day or the same business day for calls received after midnight on Monday-Friday. Any email communication received after hours will be responded to the following business day or the same business day for emails received after midnight on Monday-Friday.
Phone:
- Oregon: (541) 684-5584 or (888) 691-8209, ext. 2584
- Idaho: (208) 333-1563 or (800) 688-5008
- Montana: (406) 442-6595 or (877) 570-1563
TTY: (800) 735-2900
FAX:
- Oregon: (541) 225-3625
- Idaho: (208) 333-1597
- Montana: (406) 441-3378
Email: healthservices@pacificsource.com
Contact for:
- Referrals
- Case management
- Utilization review
- Preauthorization
- Out-of-panel referral information
- Specific medical necessity criteria/guidelines
Quality
Risk Adjustment for Quality Patient Care
Risk adjustment is a methodology used by both the Centers for Medicare and Medicaid Services (CMS for Medicare Advantage) and Health and Human Services (HHS for commercial plans) to predict healthcare needs and costs based on the overall health of patients. Under the Affordable Care Act (ACA), all Medicare Advantage and Commercial plans are required to submit information on patient health status annually to help establish the costs of patient care for the next year and reimbursement to the health plan.
But risk adjustment is much more than a regulatory requirement. It actually improves quality of care in several ways. Accurate identification of patient health status allows us to:
- Understand patient needs so new programs and interventions can be developed
- Identify high-risk patients for disease and intervention management programs
- Integrate clinical efforts with clinics and provide more robust data
How does risk adjustment work?
Patients are given a risk score based on:
- Demographic status (age, gender, etc.)
- Health status - International Classification of Diseases (ICD) code set
Risk adjustment methodology groups ICD codes into Hierarchical Condition Categories (HCC) based on health conditions that require similar healthcare needs.
Why are documentation and coding so important?
Patient health status (acute, chronic, and status conditions) must be addressed, documented, and coded during a face-to-face visit each year based on CMS guidelines. The information to support health status of patients is collected through ICD codes submitted on claims or captured in medical record review. This detailed and accurate documentation of the patient's health status is critical and affects patient care, treatment, and management.
How can I ensure my documentation supports the diagnosis codes I select?
Document clearly and concisely how the conditions coded were assessed, monitored, evaluated, and/or treated during the visit. Every encounter with a patient is an opportunity to assess their overall health and comprehensively document chronic conditions, coexisting acute conditions, and active status conditions, as well as pertinent past conditions.
Thank you for taking the time for this documentation.
We know how busy you are caring for your patients, and we appreciate your efforts. Please know that these extra documentation steps make a big difference in care quality.
Quality Improvement Program Goals and Progress
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
- 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.
Clinical Practice and Preventive Health Guidelines
PacificSource Health Plans uses nationally recognized clinical practice and preventive health guidelines as the basis for our Condition Management and Quality Improvement programs. These guidelines are available at PacificSource.com/provider/practice-guidelines, including guidelines for diabetes, CAD, depression, ADHD, prenatal care, adult and child immunizations, preventive health, and more.
Affirmative Statement about Incentives
PacificSource Health Plan's 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 a per-case-reviewed basis or population-management basis, regardless of coverage determinations.