Please contact our Provider Service Department to:
- Request provider education
- Request on-site visits
- Receive assistance with training or troubleshooting InTouch for Providers
- Request allowed amounts
- Ask questions about claims
- Research claim denial
- Ask questions about 835/EFT
Please contact our Provider Credentialing Department if you have general credentialing questions, or you would like to check the status of credentialing or re-credentialing.
Oregon & Washington
Please contact our Provider Contracting team if you have general contract questions, would like to request a new contract, check the status of a contract, or renegotiate rates.
Our Provider Operations team can help you:
- 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
Through InTouch for Providers, you can access claims, request and check the status of prior authorizations, and view member benefit information any time. The site is available through OneHealthPort, a single portal used by multiple insurers.
The PacificSource Provider Manual for contracted providers is 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.
It provides critical information regarding provider and plan responsibilities, and should be used in conjunction with your contract with PacificSource. Please take a moment to look over the sections that relate to your responsibilities. You will also find the expanded glossary helpful in becoming familiar with common insurance terminology. Of course, your comments, questions and/or suggestions are always welcome.
Our Provider Bulletin 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. Current and recent articles can be found on our Articles page.
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.
If your patient is a new PacificSource member or is a current member needing a new card, they can print an ID card. They will need their plan information to fill in the required fields and generate a card.
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 an 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.
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."
If you have any questions, please feel free to contact your Provider Service Representative.
Information about PacificSource Health Plans' pharmacy program is available on our Prescription Drug Lists and News page. 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 prior authorization requirements
- Explanation of limits or requirements
- How to provide information to support an exception (prior authorization process)
- Generic substitution, therapeutic interchange, and step-therapy protocols
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 Member Rights and Responsibilities information in the PacificSource Provider Manual.
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 while 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.
To be sure you always have the most current information about our Condition Support programs, please see our Provider Manual.
Here you will find instructions on how to use condition support services and how PacificSource works with patients in the program.
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 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 through 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 team by phone at 888-691-8209 or by fax: 541-225-3625.
If electronic communication is preferred, you may contact our Health Services team securely via the Contact Us page.
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, Monday through Friday. Any email communication received after hours will be responded to the following business day, Monday through Friday.
- Case management
- Utilization review
- Prior authorization
- Out-of-panel referral information
- Specific medical necessity criteria/guidelines
As a provider, you’re in a key position to make a real difference to patients who may be experiencing depression. Our Depression in Primary Care Program is designed to help you by supporting depression screening and treatment at the primary care level.
Depression Is Common
It’s estimated that 12 percent of patients have major depression. Depression often coexists with other serious medical illnesses, such as heart disease, stroke, cancer, HIV/AIDS, diabetes, and Parkinson’s disease. Most people do not seek treatment due to the stigma associated with depression.* In addition, a high percentage of those treated don’t continue their treatment for a sufficient period of time.
The Challenges Facing Providers and How We Can Help
We realize there are unique challenges to helping patients with depression. Patients often come in complaining of physical symptoms. Because the symptoms of depression can mimic other illnesses, recognizing them may be difficult. In a busy practice setting, there can be little time and few tools to do the depression screening you would like to do.
We can help. Our program offers your practice screening tools and support:
- Patient health questionnaire (PHQ-9), English and Spanish. This tool was specifically developed for use in primary care to screen for depression, as well as monitor response to treatment. It can be self-administered, and is quick and easy.
- Reimbursement for depression screening and follow-up monitoring
Please submit claim with CPT code 96160 or 96161 for reimbursement.
Join the Effort to Increase Depression Awareness and Screening
Medical associations are recognizing the critical role that PCPs fulfill in identifying and treating patients.
- Keep the signs of depression in mind and share them with your staff.
- Use the PHQ-9 tool to screen and monitor your patients for depression symptoms.
- Submit your depression-screening claims using the combination coding
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.
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 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 Quality Program Highlights and Progress (pdf)
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 on our Practice Guidelines page, including guidelines for diabetes, CAD, depression, ADHD, prenatal care, adult and child immunizations, preventive health, and more.
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 basis or population-management basis, regardless of coverage determinations.