In reviewing your claims, PacificSource may occasionally request additional information and/or x-rays. In these cases, please use the corrected dental claim form available on our website. If you’re asked for additional information, you don’t need to submit a new claim—just complete the corrected claim forms and send it to us.
If you’re making a change to the CDT code, please include chart notes to support the change. You’ll find corrected claim form at PacificSource.com/provider/forms-and-materials .