If you have a medical emergency, go to the nearest emergency room or call 911 for help. In other cases, please use the Contact Us form and we’ll respond the next business day. You can also access personalized information about your PacificSource coverage any time through InTouch for Members, a secure member login site. If you prefer using your phone or tablet, download the free myPacificSource mobile app.
Federal law requires all insurers to obtain and report Social Security numbers of their insured members to the Centers for Medicare and Medicaid Services (CMS). We have security measures in place to protect against wrongful release of all personally sensitive and medical health information.
If you’re covered under a group health plan, your employer is the policyholder. Contact your employer to request a copy of the insurance policy or a Member Benefit Handbook.
If you’re covered under a PacificSource individual and family plan, you received the policy when you enrolled or changed plans. You can request a replacement copy from our Individual Sales Department at 888-684-5585 or individual@pacificsource.com.
Your summary of benefits is available online at InTouch for Members, our secure member website. If you’re covered under a group plan, you’ll find a copy in your Member Benefit Handbook, or you can request one from your employer. The Summary of Benefits is included in your policy document if you have a PacificSource individual and family plan.
You can order a new member ID card any time by logging into InTouch for Members, our secure member website. You’re also welcome to use the Contact Us form to request a new card, or call our Customer Service staff at 888-977-9299 during business hours.
This is most often due to custody arrangements. For dependent children, the insurance ID card is issued only to the custodial parent. This is true even if the noncustodial parent is the primary policyholder. The child’s name will not appear on a noncustodial parent’s ID card. If this circumstance doesn’t apply to you and you believe there’s an error on your ID card, please contact our Customer Service staff at 888-977-9299 during business hours.
You can update your contact information any time by logging into InTouch for Members, our secure member website. You’re also welcome to use the Contact Us form any time, or call our Customer Service staff at 888-977-9299 during business hours.
InTouch for Members is our secure website where you can track your claims, deductibles, out-of-pocket maximums, prior authorizations, referrals, and more. Learn more, register, or log in now
As a PacificSource member, you can access CaféWell, an online health engagement portal. To get started, log into InTouch. Under the Benefits menu, choose Wellness – CaféWell.
Visit CaféWell to:
Language assistance is available by calling 866-281-1464 during our regular office hours of 8:00 a.m. to 5:00 p.m., Monday through Friday.
En Español: 866-281-1464
Our Customer Service staff is available by phone weekdays from 8:00 a.m. to 5:00 p.m. Pacific time. Our regional offices are all open weekdays from 8:00 a.m. to 5:00 p.m. local time. You’re welcome to use the Contact Us form. PacificSource Customer Service can be reached by phone during business hours at 888-977-9299 or by email at cs@pacificsource.com.
Prior authorization (preauthorization) is a prospective review of a proposed treatment that determines applicable insurance benefits, medical necessity, and appropriateness. It also may include assessment of the level of care and treatment setting.
Certain medical services and prescription drugs require prior authorization in order to be considered for coverage under your plan. In these cases, your provider must obtain prior authorization from PacificSource before the treatment is provided. Without prior authorization, you could be held responsible for payment to your provider if the services aren’t covered by your plan.
Prior authorization is a service for you and your healthcare provider that helps:
You can search our Provider Authorization Grid by procedure name or billing code. If your procedure isn’t specifically listed but might fall under one of the broad categories on our prior authorization list—such as experimental or investigational procedures—it will require further inquiry. PacificSource Customer Service can verify whether a procedure requires prior authorization if we have your procedure’s billing code. Ask your provider to call us to check on prior authorization.
Outpatient mental health and chemical dependency services do not require prior authorization; 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.
Prior authorization and concurrent review is required for inpatient, residential, partial hospitalization, and intensive outpatient mental health and chemical dependency treatment.
Our prior authorization guidelines are based on current medical evidence, clinical criteria, and medical necessity, and are reviewed and updated as needed. When considering prior authorization requests, we review all available pertinent information and we may communicate with your healthcare provider if additional information is needed.
Requests must be received in writing from your physician or healthcare provider. The prior authorization request form must be completed in full before we can begin the prior authorization process. We may require related chart notes and/or clinical information to make our determination.
We respond to prior authorization requests from healthcare providers within two business days. Processing for requests received after 3:00 p.m. begins the following business day.
As soon as a prior authorization 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 prior authorization request by logging into InTouch, or by calling our Health Services Department at 888-691-8209.
To have your claim reconsidered, ask your provider to submit a retrospective prior authorization request. The provider should include the fully completed medical prior authorization request form along with related chart notes and/or operative report to support the request. We will process the request within 30 days of receipt.
UCR—or “usual, customary, and reasonable”—usually applies to services of out-of-network or noncontracted providers. It’s the fee allowance we use to calculate benefits for dental providers and out-of-network medical providers.
The PacificSource allowable fee applies to services of contracted in-network providers. It’s the reimbursement rate we’ve negotiated under our provider contract.
It depends on your specific policy. Under most plans, once you’ve met your out-of-pocket maximum, you’ll have no further out-of-pocket expenses for services of in-network providers for the rest of the plan year. However, some plans have specific services that don’t apply to the out-of-pocket maximum, and/or services for which you continue to have a cost share even after your out-of-pocket maximum is met. Refer to your Summary of Benefits or contact PacificSource Customer Service at 888-977-9299 or cs@pacificsource.com for more information on your plan’s out-of-pocket maximum provisions.
When there’s an auto accident, your PacificSource policy’s “third-party liability” provisions apply. In third-party cases, the other coverage—in this case, auto insurance—has primary responsibility for paying your medical expenses up to that policy’s limits. Your PacificSource policy then takes over to cover any remaining medical expenses. Our Third-Party Recovery Department will work with you to help ensure that your expenses are covered.
Coverage depends on your specific plan design. In general, testing supplies (strips and lancets) and blood glucose monitors are covered under the medical plan, while insulin, syringes, and needles are covered under prescription drug benefits. Insulin infusion pumps and supplies and needle-free systems require preauthorization to determine coverage. Diabetic education is a covered benefit, and we also have a free diabetic meter program for members. For more information about your coverage, contact our Customer Service staff at 888-977-9299.
Specific mental health benefits vary and are determined by your insurance policy. Please refer to your benefit summary or Member Benefit Handbook—available through InTouch for Members—or call our Customer Service staff at 888-977-9299. Mental healthcare may include:
Our Care Coordination Request form can help you communicate your healthcare needs as a new member transitioning to PacificSource. Submitting a request is especially helpful if you have ongoing healthcare needs, are involved in an active treatment plan, and would like to verify that your treatment will be covered.
Care coordination support includes maternity care, cancer care, treatment of trauma or acute conditions, or surgery or hospitalization scheduled within 90 days of your policy’s start date. After submitting your form, you will receive a follow-up call from a Health Services Representative. Assuming guidelines are met, we’ll then assign a Nurse Case Manager to work with you during your transition with us.
Yes. The Quit for Life program includes one-on-one support and nicotine replacement therapy to help you give up tobacco for good.
No, we can’t offer à la carte benefits. Health insurance is a highly regulated industry. All health plan designs and premium rates must be filed and approved by the state insurance departments where we do business. In addition, many benefits are mandated by law—meaning federal or state regulations require insurers to provide them.
Probably not. Pre-travel immunizations are generally excluded from health plan coverage. However, a handful of employer group policies have exceptions to this rule because their employees are frequently required to travel to other parts of the world. If you think your employer includes this coverage, please contact PacificSource Customer Service at 888-977-9299 or cs@pacificsource.com.
Yes. All medical plans have seasonal flu vaccine coverage. PacificSource provides coverage for standard flu shots, high-dose flu shots, and flu nasal mist under your medical plan’s immunization benefit.
If your plan has a pharmacy benefit, you can obtain a flu vaccine shot from our participating flu shot pharmacy network at no cost. (Mist and high-dose shots are not covered under the pharmacy benefit.) Simply show your PacificSource member ID card at one of our participating flu shot clinics to receive a flu shot at no cost. PacificSource will be billed directly, with no paperwork, deductibles, or copayments required.
County Health Departments: Flu shots are covered at the in-network provider benefit level. Applicable deductibles and/or copayments will apply.
Doctor’s Office: Flu shots are covered, subject to in-network and out-of-network provider provisions. Applicable deductibles, coinsurance, and maximum allowances apply.
For more information, please visit our Flu Prevention page.
An emergency medical condition is an injury or sudden illness, including severe pain—so severe that failure to receive immediate medical attention would risk serious damage to your health (or fetus, in the case of a pregnant woman). Examples of emergency medical conditions include (but are not limited to):
Medically necessary means those services and supplies required for diagnosis or treatment of illness or injury, and that in the judgment of PacificSource are:
Coverage options vary depending on why your coverage is ending and where you live. If you are laid off, options include COBRA, Oregon continuation, Oregon portability, Oregon Medical Insurance Pool (OMIP), Idaho conversion, and individual policies.
If your employer discontinues offering health insurance altogether, options include individual and OMIP policies.
If you were covered as a dependent on a parent’s policy, options include individual and OMIP policies.
Our Individual Sales staff is knowledgeable about all of these coverage types and would be happy to help you evaluate your options. Contact them at 888-684-5585 or individual@pacificsource.com.
Yes, as long as the child remains unmarried and intends to return to college in the fall.
If a dependent child isn’t enrolled in college, they can stay on your policy until age 26. Their coverage will automatically end on the last day of the month in which they turn 26.
Yes. Adult children can now remain on their parents’ plan until age 26.
Yes. Continuation coverage is not dependent on your state of residence.
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, quality of life, and reducing healthcare costs.
Our case managers are registered nurses 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:
If you think you might benefit from case management, please contact our Health Services Department at 888-691-8209.
Mail individual policy premium payments to:
PacificSource, PO Box 35124, Seattle WA 98124-5124
Mail group policy premium payments to:
PacificSource, PO Box 35123, Seattle WA 98124-5123
No. Please pay as billed rather than making adjustments to your statement. We will adjust your premium for the enrollment change on your next monthly statement. “Paying as billed” helps eliminate mistakes when reconciling monthly premiums.
No. We do not bill any premium for late enrollees during the waiting period. Enrollees will be included on your bill once the waiting period is satisfied.
While your group policy premium is due on the first day of the coverage month, members on continuation coverage have until the last day of that month to pay their premium. If you’ve not received a former employee’s premium by the time you make your monthly premium payment, you have two options:
1. Keep the former employee on your plan by including their premium in your monthly payment to us. You can then attempt to collect the premium, and terminate their coverage retroactively if premium is still not paid by the end of the month. To terminate the coverage retroactively, submit your request in writing to your PacificSource Membership Service Representative. We will then make the premium adjustment on your next bill, provided no claims have been reimbursed for that month.
2. Terminate the former employee’s coverage back to the last day of the last month for which the premium was received. If the employee then submits the current month’s premium to you by the last day of that month, you’ll need to reinstate their coverage. To do so, contact your Membership Service Representative to request the member’s reinstatement; then fax us receipt of their premium payment. We will then make the premium adjustment on your next month’s billing.
If your policy was terminated for nonpayment, it’s because we did not receive and post your payment before the end of the month for which it was due. If we have not received and posted your payment to our system during the coverage month, the policy will automatically terminate on the last day of that month. The termination will be retroactive to the last day of the last month for which the premium was received.
Group policy premiums are due on the first day of the coverage month. Premium payments are received at a secure lockbox—not at our offices—so we are unable to rely on a postmark to determine whether your payment was timely.
PacificSource honors and upholds the right of every member to express concern about their coverage and quality of care, to receive information about our services and providers, to participate in decision-making regarding their healthcare, and above all, to be treated with respect and recognition of their dignity and right to privacy.
We understand that inevitably, questions or feedback regarding coverage may arise. We pledge to address your concerns thoroughly and fairly, and to resolve them as quickly as possible. In medically urgent situations, we will expedite the review process to ensure that decisions are made in a timely manner so our members receive the care they need
We classify concerns received from our members in the following ways:
Concern means any expression—written or verbal—of dissatisfaction with PacificSource.
Inquiry means a written request for information or clarification about any matter related to a member’s health plan. An inquiry is not a complaint or grievance.
Complaint means an expression of dissatisfaction about a specific problem encountered by a member, treatment by a provider, or decision made by PacificSource. A complaint must include a request for action to resolve the problem or change the decision. Grievances and appeals fall under this category.
For concerns, inquiries, and complaints, we follow an informal review process, especially if the issue can be resolved fairly easily. If a member’s complaint is identified as either a grievance or an appeal (or written and designated as a grievance or appeal), we follow what’s called a formal review to determine how it can be resolved.
An informal review is the process by which we respond to verbal concerns or complaints and all inquiries. Every effort is made to resolve issues at this level, and informal review matters are often resolved within a single phone call. These issues are most often day-to-day matters, such as verification of benefits or eligibility, interpretation of the insurance contract, clarifications of billing statements or EOB statements, and case management matters.
A formal review is how we usually respond to grievances and appeals. This level of review follows a four-part process to investigate, resolve, document, and report grievances and appeals. Once we establish that a formal review is necessary, the grievance or appeal is forwarded to a Grievance Coordinator, who is responsible for coordinating a review of the matter and keeping the member informed about our decision.
Complaints about healthcare coverage or quality of care fall into one of two categories:
A grievance is a written complaint submitted by a member (or on the member’s behalf) about the quality of services PacificSource offers. This can include issues such as the availability, delivery, or quality of healthcare services; utilization review decisions; or claims payment, handling, or reimbursement for services. You should file a grievance if you believe that medically necessary care that is covered by your health plan has been denied, reduced, or ended unduly and you want to receive care.
An appeal is a written request submitted by a member (or on the member’s behalf) requesting reconsideration of a previous decision we made in the grievance and appeals process.
Before submitting a grievance, we suggest you contact our Customer Service Department with your concerns. Issues can often be resolved at this level. You can reach us at 888-977-9299 or cs@pacificsource.com.
Otherwise, you may file a 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.
Yes. If you are unsure of what to say or how to prepare a grievance, please contact our Customer Service Department at 888-977-9299 or cs@pacificsource.com. We will help you through the process and answer any questions you have.
That depends on the degree of the issue. Your grievance or appeal will be forwarded to a Grievance Coordinator; within seven days we’ll send an acknowledgement that your complaint has been received. Then you’ll receive notice of a decision on your matter within 30 days of filing the complaint. If your complaint requires longer than 30 days, we’ll send you a notice explaining the reason for the delay. You should receive a final decision no more than 45 days after filing your complaint. If your situation is urgent, the Grievance Coordinator will work with you to ensure that your grievance or appeal is resolved as quickly as possible.
Along with notice of our decision, we will provide you with information on how to file an appeal at the next level.
Under certain circumstances, you may have the right to have your case reviewed by an external independent review organization to dispute our decision on your appeal. If we denied benefits because we determined that services were not medically necessary or were experimental or investigational, you have this right. In addition, if you believe you have a right to continue treatment with a provider who is no longer eligible for payment by us, your appeal may be reviewed externally. Your request for an independent review must be made within 180 days after you receive our final decision. External independent review is available at no cost to you, but is only an option for issues of medical necessity, experimental or investigational treatment, and continuity of care after all internal grievance levels are exhausted.
Yes. We have an online Provider Directory to help you find providers in your area, or create a printable directory of providers based on your criteria. The online directory is updated frequently, so you may wish to check in periodically.
Check your PacificSource Member ID card for your plan name. You’ll find it just below the PacificSource logo. You'll also find your plan name in the Medical Plan Info section of InTouch for Members.
Yes, although you’ll receive your plan’s highest level of benefits by using in-network providers. Your out-of-pocket costs are going to be higher with treatment from an out-of-network provider. See your plan’s Summary of Benefits (available at InTouch for Members), or contact our Customer Service staff at 888-977-9299 or cs@pacificsource.com for coverage information.
You can use our Provider Nomination Form to ask your healthcare provider to consider joining the PacificSource network.
This is a rare occurrence, but if it happens we’ll help ensure that you receive appropriate continuity of care. We’ll provide you with written notice that the provider’s contract will be terminating. We will allow for you to continue treatment by that provider under your plan's in-network provider benefit level for a period of time after the contract terminates. Our Health Services team will also help you transition your care to a new in-network provider when appropriate. If you choose to continue seeing the provider, your plan's out-of-network provider benefit level will then apply.
A referral is the process by which your primary care provider (PCP) directs you to other providers, usually specialists, for further care. Some health plans require you to get a formal referral from your PCP before you see a specialist or other type of provider. When appropriate, your PCP will request a referral from PacificSource on your behalf.
Network Not Available (NNA) is a PacificSource determination, which means members wouldn’t have reasonable geographic access to a particular provider or medical facility. In some cases, we may make certain exceptions to a plan’s network benefits. If you think this may apply to your situation, please contact Customer Service at 888-977-9299 or cs@pacificsource.com.
When traveling outside Idaho, Montana, Oregon, and Washington, members are able to stay in-network nationally through our partnership with First Health Network and with First Choice Health Network (in Alaska). (Members also have access to care through telehealth services from their mobile device or computer.) Also, when members are 100 or more miles away from home or out of the country, Assist America is available to help coordinate resources in case of an emergency.
When members are 100 or more miles away from home or out of the country, Assist America is available to help coordinate resources in case of an emergency.
Most of our dental plans don't rely on a network of participating dentists. You may visit any dentist, and your plan will cover reasonable and customary charges for the area where services are rendered. If you have a Dental Advantage Essentials plan, you can use our online Provider Directory to find an in-network dentist.
There are many types of qualified mental health professionals, and individual practitioners often specialize in certain types of patients or cases. A good first step is to ask your primary care doctor to recommend a mental health professional with the qualifications and experience to treat your condition. Then use our online Provider Directory to confirm that the provider participates in the PacificSource network. You’ll receive your plan’s highest level of benefits if you use in-network providers.
The providers listed below are those trained in different areas of mental healthcare:
Psychiatrist: A licensed medical doctor who specializes in the diagnosis, treatment, and prevention of mental illnesses. They may work with you on problems like depression, or more complex issues like schizophrenia. Psychiatrists can prescribe medications.
Psychologist: A licensed specialist who provides clinical therapy or counseling for a variety of mental healthcare conditions. They have earned a doctorate degree in psychology and are required to complete several years of supervised practice before becoming licensed.
Counselor/Therapist: A specialist who provides mental health services to diagnose and treat mental and emotional health issues. They may use a variety of therapeutic techniques.
Licensed Counselors: Professionals with a master’s or doctoral degree in counseling or a related area.
Neuropsychologist: A licensed psychologist with expertise in how behavior and motor skills are related to brain structures and systems.
Social Worker: A specialist who provides treatment for social and health problems. Some social workers may work in employee assistance programs or as case managers who coordinate psychiatric, medical, and other services on your behalf. Others specialize in domestic violence or chronic illness. Most social workers have a master’s degree in social work; many are licensed as a LCSW.
Psychiatric Nurse: Licensed registered nurses (R.N.) who have extra training in mental health. Under supervision of medical doctors, they may offer mental health assessments and psychotherapy and they may help manage medications. Advanced practice registered nurses (A.P.R.N.) can diagnose and treat mental illnesses.
Marriage and Family Therapist (MFT): Therapists who evaluate and treat disorders within the context of the family. These therapists provide help with a range of problems, such as depression, parent-child conflicts, and eating disorders.
Your insurance contract with PacificSource includes two eligibility qualifications for employee coverage: the minimum number of hours worked, and the employee probationary period. Those eligibility qualifications are set by the employer, and the employer must treat all employees of the same employment class equally. If an employee has been employed for the number of days required by your probationary period, and is working the minimum hours required by your plan, then you’re obligated to offer coverage under your group plan.
You can remove members from your plan online using InTouch for Employers portal. You can also contact your Membership Service Representative in writing (via fax, mail, or email) to request that we remove members from your plan. We’re unable to accept member termination requests by phone, as we need written documentation for our records.
It depends how much time has elapsed since the original eligibility date.
If the original eligibility date was within the current month or the prior month, we can retroactively enroll the employee back to that original eligibility date.
If the original eligibility date was prior to last month, the policy’s late enrollee provisions will apply. The employee will be subject to a six-month wait—beginning the first day of the month after we receive the enrollment application—before coverage can begin.
Dependents can be added to an employee’s coverage at the time of a “qualifying event” defined in the policy. Those events include involuntary loss of other coverage, return to school (for group plans that have a full-time student requirement), marriage, birth, or adoption. For dependents seeking enrollment without a qualifying event, the policy’s late enrollee provisions apply. The dependent is subject to a six-month wait—beginning the first day of the month after we receive the enrollment application—before coverage can begin.
If you’ve tried to log in seven times and are locked out, the "Forgot My Password" link will no longer work. Contact us to help you reset your password at 888-977-9299 during business hours, or by email at cs@pacificsource.com.
This can occur if punctuation or special characters are used in the hint answers. Please try again without any punctuation or special characters.
No, they are not case-sensitive.
Contact our Customer Service staff. You can reach us at 888-977-9299 during business hours, or at cs@pacificsource.com. Or, use the Contact Us form to get help with your question. Be sure to include as much detail as possible: your member ID number, a description of what you're trying to do, and notes about any error message. Please provide either a daytime phone number where we can call you, or a current email address, so we can follow up promptly
You can reach the InTouch for Agents team at 800-624-6052 during business hours, or at intouchforagents@pacificsource.com. Or, you can use the Contact Us form. Please provide as many details as you can: your Producer number, the name of the group you are quoting, a detailed description of the problem you are encountering, any error message you are receiving, and screen shots if possible.
You are welcome to contact our Provider Network Department at 541-684-5580 or 800-624-6052. Or contact your Provider Service Representative directly. Please provide as many details as you can: your NPI, a detailed description of the problem you’re encountering, any error message you’re receiving, and screen shots if possible.
Benefit summaries are specific to each member. Once you're logged into InTouch for Employers, perform a member search to pull up the specific member's record, and you can then access that member’s plan summaries.
Not at this time. We do offer premium payment by electronic funds transfer, however. Contact your PacificSource Membership Representative for more information.
Yes. The member must register for InTouch for Members using the new group number, even if the new number is not yet in effect.
No. To change a subscriber's last name, please contact your PacificSource Membership Representative.
No. To change a dependent's date of birth, please contact your PacificSource Membership Representative.
If our system already contains separate mailing and home addresses for a subscriber (employee enrolled in your health plan), then you can change the mailing address online without also changing the home address. Otherwise, any update you make to the home address will automatically update the mailing address (even though it won't appear that you’ve made that change). To add a separate mailing address after the subscriber is enrolled, please contact your PacificSource Membership Representative.
Type the employee’s Zip code in the “Zip” field and then click the “Look-up” button. A window will appear listing all towns within that Zip code. Click the Zip code link next to the correct entry and the city, county, and state fields will auto-populate.
A few potential causes:
Please contact the InTouch for Employers Team for assistance at 541-225-3742 or intouch4admins@pacificsource.com. Please provide as many details as you can: most important are your group number, the subscriber's name, the subgroup and class you are using, and a description of the error.
No. When the subscriber is terminated, all dependents are automatically terminated as well.
Other Coverage information and Prior Coverage information doesn’t currently translate directly into our database. If you have these details during a new enrollment or reinstatement, please contact your Membership Representative or the InTouch for Employers team after processing the online enrollment.
Please contact our InTouch for Employers team for assistance at 541-225-3742 or intouch4admins@pacificsource.com. Please provide as many details as you can: most important are your group number, the subscriber's name, the subgroup and class you are using, and a description of the error.
