Questions about your health plan? Find answers here

If you have a true medical emergency, always go directly to the nearest emergency room, or call 911 for help.

If you're facing a non-life-threatening emergency, contact your doctor's office, or go to an urgent care facility. In-network urgent care centers are listed in our online provider directory. Simply enter your city and state or zip code, then select "Urgent Care" in the "Specialty Category" field.

Don't have a doctor yet? Let us help you find one. See our Find a Doctor page.

Not sure if you should go to ER or urgent care? See our Urgent and Emergency Care guide.

Always show your PacificSource member ID at your doctor's office or pharmacy. Your member ID gives providers the information they need to submit claims on your behalf.

For new members:

If you haven't already received one, a member ID may be mailed to your home soon. If you need to order prescriptions or access medical services before your new ID card arrives, you can print your member ID.

Note: Your plan must be active in order to print an ID. If your plan starts at a future date (for example, the first of next month), you'll need to wait until that date to print a member ID.

For current members:

Please call Customer Service or visit InTouch for Members to request a new ID. From InTouch, you can also print an ID to use until your replacement card arrives.

Note: Your member ID will only show your eligibility in effect on the day you print your ID. If you are a renewing member and have upcoming changes to your plan, your new eligibility will show on your ID only after your plan's renewal date.

Your PacificSource member handbook or policy provides specific information about benefits and services covered by your plan.

This information is available to you 24/7 online through our secure member portal, InTouch for Members. You'll need to register when you use InTouch for the first time. All you need is a valid email address, your member ID number (on your member ID card), or your Social Security number.

Flu shots

Flu shots are typically covered by your PacificSource plan. Learn more on our Flu Prevention page.

Exclusions

Your plan may exclude some procedures, services, and medications. You'll find information specific to your plan in your member handbook or policy. Your member handbook or benefits summary is available through InTouch.

You're welcome to contact Customer Service if you have questions or need assistance.

To learn more about what costs you may have to pay as part of your plan, such as copayments and deductibles, see your member handbook or benefit summary. These documents are available through InTouch for Members.

You're also welcome to contact Customer Service for assistance.

Your EOB is a summary of recent services you've had, such as a doctor visit or lab work. It tells you how much the doctor billed, how much your plan paid, and the balance, if any, you owe to your provider. You'll also find deductible balance and other information. If you have questions about how to read your EOB, check out our Your explanation of benefits (EOB) page.

Your EOB statement will be sent to you after we have processed a claim. Depending on the delivery method you have selected, you will either receive a paper statement by mail or an email notice. If you have questions or want to check the status of a claim, you are always welcome to contact our Customer Service team.

Use our online Provider Directory to find a doctor or other provider, and more information about those doctors and providers. See our Find a doctor page to get started.

See your member ID, member handbook, or policy for your specific plan information. You can search by specialty, name, location, or other details to access a list of providers that fit your criteria. Or you can create your own personalized provider directory to download and print.

Customer Service can also help you find doctors, dentists, and hospitals in your area and provide details about their services and professional qualifications. 

To maximize your plan's benefits, always make sure your healthcare provider is in your plan’s network. If your plan has more than one tier of participating providers (indicated in our online provider directory by tier 1 or tier 2), you'll get the most value from your plan by selecting a tier 1 provider. If you receive services from an out-of-network provider, it may result in greater out-of-pocket costs to you. 

Please refer to your member handbook or policy, or log in to InTouch, to find detailed information about out-of-network benefits and coverage.

Choosing a primary care provider (PCP)

We recommend all members select a primary care provider. He or she will work with you to help you maintain your health and coordinate your care. 

Learn how to find and designate your PCP

To find in-network specialists, behavioral health providers, and hospitals. Simply go to the Provider Directory, then use the "specialty category" and "specialty" drop-down menus when searching.

If you are unable to find an appointment with a provider within 15 business days for non-urgent issues, we will assist in connecting you to community providers to get the care you need. Please contact Customer Service for assistance or call the number on the back of your member ID card.

Resources for people who are experiencing a behavioral health crisis, including the national suicide prevention line

Mental Health and Substance Use Disorder (SUD) Resources For Immediate Help:

National Suicide Prevention Lifeline: 800-273-8255; TTY 711

Provides free, confidential, 24/7 support to people in suicidal crisis or emotional distress. The lifeline is for anyone who is (or knows someone who is) depressed or going through a hard time, needs to talk, or is thinking about suicide.

SAMHSA Helpline: 800-662-HELP (4357); TTY 711

Provides free, confidential, 24/7 treatment referral and information. It’s for people dealing with mental illness and substance use disorders, as well as their family members.

Crisis Connections serves Washington residents with programs including:

24-Hour Crisis Line: 866-427-4747; TTY 711 
Immediate help for individuals, families, and friends of people in emotional crisis.

King County 2-1-1: 800-621-4636; TTY 711 
Information on health and human services in King County, including housing assistance and help with financial needs, available Mon.–Fri., 8:00 a.m.–6:00 p.m.

Teen Link: 866-833-6546; TTY 711 
Confidential, anonymous help line for teens to talk with trained teen volunteers about any issue, available every evening 6:00 p.m.–10:00 p.m.

Washington Recovery Help Line: 866-789-1511; TTY 711 
Confidential, anonymous, 24/7 crisis intervention and referral services help line for issues related to alcohol or substance use disorders, or problems related to gambling.

Washington Warm Line: 877-500-9276; TTY 711 
Confidential, peer-support help line for people living with emotional and mental health challenges, answered by trained volunteers who have lived with mental health challenges, available Mon.–Fri., 5:00 p.m.–9:00 p.m. and weekends 12:30 p.m.–9:00 p.m.

Find a specialist, behavioral health provider, or hospital

If you or someone on your health plan is 18 years old or turning 18 this calendar year, it’s time to consider transitioning to a primary care provider (PCP) for adults. This type of PCP can be a provider who specializes in family practice, general practice, geriatrics, internal medicine, or obstetrics-gynecology. Learn more about selecting a PCP.

When traveling out of our network service area, you have access to providers and facilities nationwide through our travel provider networks.

You will receive your plan's in-network benefits when you use Aetna PPO (Aetna Signature Administrators^®) providers for services outside your plan's service area. Your member handbook or policy provides specific information about your plan's provider network and service area.

Traveling internationally? 

If you need urgent or emergency care while travelling abroad, obtain a bill including the date you received services, an itemized list of all services performed, the diagnosis and fees charged. If you or a family member are admitted to a hospital, you, or the person you’ve authorized to speak on your behalf, must notify us at 888-691-8209; TTY 711 as soon as possible. Use country code 001 from outside the United States. 

Submit this itemized bill to PacificSource by mail or fax and make sure to include the name of the member who received services, along with the group number and ID number. We will reimburse you for the itemized services that are covered under your plan, up to the amount specified by your plan.

Services that are not urgent or emergent may require preauthorization and might not be covered. Please see your plan materials for more information, or call us at 888-691-8209; TTY 711.

When traveling more than 100 miles from home or abroad, you also have access to emergency travel assistance through our global emergency services partner, Assist America.

Out-of-network liability and balance billing

PacificSource bases payment to out-of-network providers on our “allowable fee,” which is derived from several sources, depending on the service or supply and the geographical area where it is provided. The allowable fee may be based on data collected from the Centers for Medicare and Medicaid Service (CMS), other nationally recognized databases, or PacificSource. 

For more information, see your member handbook or policy.

Find a pharmacy

If your health plan includes a prescription drug benefit, you can receive your medications at a pharmacy near you. Here's how:

1. Find an in-network pharmacy in your area.
2. Show your PacificSource member ID when you drop off your prescription(s).
3. Pay your share of the drug's cost. PacificSource will be billed directly for the balance.

Learn more about using our pharmacy network

If your medical plan uses our Preferred Drug List (PDL), our prescription discount program can help you save money on eligible medications that aren't covered, when you shop at a participating CVS Caremark^® pharmacy.

Find out which drugs are covered

See your member handbook or policy for information about your pharmacy coverage and which drug lists apply to your plan. Then, find your drug list on our drug list page.

Our drug lists are guides to help your doctor identify medications that can provide the best clinical results at the lowest cost. As a cost savings for you, generic drugs are included in place of name brand drugs whenever possible. Drug lists are reviewed monthly.

Step therapy

Some drugs may require prior authorization, or be part of a step-therapy process. Step therapy requires the trial of one or more prerequisite medications before a specific medication is covered. Drugs not listed on our drug lists are not covered.

Recent changes, and more information about drug lists, prior authorization, and our step-therapy process, can be found on our Drug lists and news page.

Helpful links

• PacificSource Drug Lists: Our comprehensive drug list page. You'll also find links to information about prior authorization and step therapy.
• Prescription drug claim form: Use this if you paid for a covered medication up front and need to be reimbursed.

Prior authorizations for prescription drugs

PacificSource requires written prior authorization for coverage of certain medical services, surgical procedures, and prescription drugs.

Learn how prior authorization works

To request a prescription drug prior authorization, have your prescribing doctor complete our Prescription Drug Prior Authorization Request form. Information about drugs that require prior authorization is available on our drug list page.

Limits and requirements

Some plans may have limits or requirements for certain drugs. Refer to your member handbook or policy for more information, or contact Pharmacy Customer Service for help.

To request a prescription drug exception

If your drug is not included on the drug list on our drug list page, you should first contact Customer Service and confirm that your drug is not covered. You and your provider have the right to request an exception to the plan’s formulary or coverage criteria. If you would like to request an exception, contact Customer Service at (888) 977-9299, or have your provider submit documentation through InTouch, fax, or phone using the Prior Authorization/Medication Exception Request form.

When considering drug exception requests, we review all pertinent information available, and we may communicate with your provider if additional clinical information is needed. For nonformulary drugs to be covered, your provider should offer clinical information indicating that all of the formulary alternatives would be ineffective or would have adverse effects in the treatment of your medical condition.

We respond to prior authorization and exception requests from providers and members within two business days for standard requests. Expedited requests are addressed within 24 hours. 

As soon as a determination is made, we notify the member, physician, and facility or vendor. You and your provider can also check the status of your request by logging in to InTouch, or by contacting Customer Service.

Reproductive health coverage in Oregon

The state of Oregon requires all health benefit plans to cover certain services, drugs, devices, products, and procedures relating to reproductive health and functioning. All PacificSource plans comply with these rules, which you can read at the OregonLaws.org website.

Check your member handbook or policy for complete details on your plan’s coverage of contraceptives and other reproductive health matters.

If for any reason the policyholder, policyholder estate, or entity cancels coverage under this policy, the policyholder, policyholder’s estate, or entity shall notify PacificSource on a timely basis. PacificSource will refund to the policyholder, policyholder’s estate, or entity any unused premium received for the period of ineligibility.

“Unused collected premium” means that portion of any premium collected which is not used, on a pro-rata basis to the beginning of the next billing cycle at the time of cancellation, by PacificSource to insure against loss when there is no risk of loss, or that portion of any collected premium which would have not been collected had the policyholder paid monthly.

If your coverage is through an employer group plan, contact your employer to request a refund due to premium overpayments.

If you are an individual policyholder, we issue premium refunds within 30 days of your request or cancellation of your policy. Refunds due to cancellations are processed automatically, and do not require any action from the policyholder. Refund requests due to overpayment of premium can be made via written request, email, or phone. Contact the Membership Services Department toll-free at 800-591-6579, by email at individualbilling@pacificsource.com, or by mail at

PacificSource Health Plans
Attn: Individual Billing
PO Box 7068
Springfield, OR 97475

PacificSource bases payment to non-participating providers on our “allowable fee,” which is derived from several sources, depending on the service or supply and the geographical area where it is provided. The allowable fee may be based on data collected from the Centers for Medicare and Medicaid Service (CMS), other nationally recognized databases, or PacificSource.

To calculate our payment to non-participating providers, we determine the allowable fee, then subtract the non-participating provider benefits shown in the ‘Non-participating Provider’ column of your Medical Schedule of Benefits. Our allowable fee is often less than the non-participating provider’s charge. In that case, the difference between our allowable fee and the provider’s billed charge is also your responsibility. That amount does not count toward this plan’s out-of-pocket maximum. It also does not apply toward any deductibles or co-payments required by the plan. In any case, after any copayments or deductibles, the amount PacificSource pays to a non-participating provider will not be less than 50 percent of the allowable fee for a like service or supply.

In Oregon, there is an exception to the out-of-network liability for the difference between our allowable fee and the providers charge if you receive incidental services. Incidental services include services performed by an out-of-network radiologist, pathologist, anesthesiologist, or emergency room physician, which you had no control over, while inpatient or outpatient at an in-network facility.

Effective January 1, 2019, the Surprise Billing mandate states that we must process these claims based on a set fee allowance (ranges per procedure code and per county), and the provider cannot collect from you the difference above that set fee. Therefore, for incidental services incurred on or after January 1, 2019, the provider should not bill you for the difference between the allowed amount and the providers charge. These claims are processed at your in-network benefit and you can only be billed for any applicable deductible, copay, or coinsurance applied to the claim.

If you are on a Washington plan, there is a Balance Billing Protection Act that was effective January 1, 2020. It also applies to providers in Oregon and Idaho. It applies to incidental services performed by an out-of-network radiologist, pathologist, anesthesiologist, or emergency room physician which you had no control over, while being treated as inpatient or outpatient at an in-network facility. Claims are priced according to the rule, and you cannot be balance billed for the difference above the allowed amount. Your balance will be any amount that was applied to your deductible, copay or coinsurance.

In Montana, there is an exception to the out-of-network liability for the difference between our allowable fee and the providers charge if you receive services for an emergency medical condition from an air ambulance provider who is non-Montana hospital-controlled. The controlling regulation is found at https://leg.mt.gov/bills/mca/title_0330/chapter_0020/part_0230/section_0020/0330-0020-0230-0020.html which states that an enrollee is to be held harmless and it is up to the carrier and air ambulance provider to resolve the reimbursement amount.

InTouch lets you securely access your insurance information and a wealth of health resources.

• Look up a claim
• See plan benefits
• View deductible or
• Pay your bill online

Log in to InTouch

New and emerging medical procedures, medications, treatments, and technologies are often marketed to the public or prescribed by physicians before FDA approval, or before research is available in qualified peer-reviewed literature to show they provide safe, long-term positive outcomes for patients.

To ensure you receive the highest quality care at the lowest possible cost, we review new and emerging technologies and medications on a regular basis. Our internal committees and Health Services staff make decisions about PacificSource coverage of these methods and medications based on literature reviews, standards of care and coverage, consultations, and review of evidence-based criteria with medical advisors and experts.

To access your personal health records, contact Customer Service. You'll also find the forms you need to authorize and restrict access on our Documents and forms page.

Case management is a service available to all PacificSource members who have complex medical conditions and require support to manage their healthcare needs. It is a service aimed at improving health outcomes, increasing member satisfaction with their healthcare, and reducing healthcare costs.

Our case managers are registered nurses and licensed mental health professionals 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 help members experiencing a wide range of complex medical issues, such as:

• Extended hospital or skilled nursing care
• Cancer diagnoses, especially those needing help with a new diagnosis
• Children with special needs
• Chronic and/or rare diseases and conditions
• Eating disorders, such as anorexia nervosa or bulimia nervosa

If you think you might benefit from case management, you're welcome to contact our Health Services Department Monday through Friday, 8:00 a.m. to 5:00 p.m.

• Oregon: 888-691-8209 
• Idaho: 800-688-5008 
• Montana: 877-570-1563 
• TTY: 711 
• Language assistance: 866-281-1464 
• Contact Us

Our Condition Support Program offers education and support to members with asthma, diabetes, heart failure, chronic obstructive pulmonary disease, coronary artery disease, or pediatric diabetes at no additional cost.

This voluntary program is available to all PacificSource members with medical coverage. Members covered under self-funded groups are eligible only if their employer has purchased the option. Other eligibility requirements may apply.

If you feel you or a covered family member may qualify for this program, and you have not yet been contacted by us, please contact a Health Services representative about your eligibility.

Toll-free: 888-987-5805

Email: yoursupport@pacificsource.com

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 Quality Program highlights and progress (PDF)

Our Utilization Management (UM) program is in place to ensure our members receive appropriate, effective, and efficient medical care. It includes medical services, medical equipment, and pharmacy.

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 your plan 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.

PacificSource 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.

Utilization Management staff availability

Health Services staff is available eight hours a day, on normal business days, to answer utilization management related questions.

Our hours are Monday – Friday, 8:00 a.m. to 5:00 p.m.

After normal business hours

We accept emails and faxes after normal business hours. Calls after business hours are forwarded to our confidential voicemail. A Health Services representative will respond the next business day if received before midnight. Calls, emails, or faxes received after midnight will be addressed that day, during business hours.

Contact us or call, toll-free:

• Oregon: 888-691-8209
• Idaho: 800-688-5008
• Montana: 877-570-1563
• TTY: 711
• Language assistance: 866-281-1464

PacificSource may work with other companies to help manage your health plan benefits. 

These companies are called healthcare benefit managers. A healthcare benefit manager is any person or organization that provides services to, or acts on behalf of, a health insurance carrier or employee benefits program. Healthcare benefit managers may directly or indirectly affect your plan benefits or access to healthcare services, drugs, or supplies. Services they provide may include, but are not limited to: 

• Prior authorization of benefits or care
• Certification of benefits or care
• Medical necessity determinations
• Utilization review
• Benefit determinations
• Claims processing and repricing
• Outcome management
• Payment or authorization of payment to providers and facilities 
• Dispute resolution, grievances, or appeals relating to determinations or utilization of benefits
• Provider network management
• Disease management

Here’s a list of healthcare benefit managers we use and the services they perform:

Please note: this list is subject to change. 
 

Download the healthcare benefit managers information as a PDF. 

In an emergency, you should go to the nearest hospital. When you can plan ahead, try the following websites. Discuss the information you find with your doctor to decide which hospital will best meet your healthcare needs.

Leapfrog Group Hospital Ratings —features nationwide hospital quality information. Includes hospital comparisons of overall patient safety ratings, as well as safety of selected procedures.

Hospital Compare— information about the quality of care at more than 4,000 Medicare-certified hospitals across the country, including over 130 Veterans Administration (VA) medical centers. The tool was created through the efforts of the Centers for Medicare & Medicaid Services in collaboration with organizations representing consumers, hospitals, doctors, employers, accrediting organizations, and other federal agencies.

Oregon Hospital Guide —includes charges and utilization information for Oregon hospitals. Includes data on the most common types of hospitalizations in Oregon; alcohol and drug abuse; bones, joints, muscles; heart/cardiovascular; psychiatric; and rehabilitation.

Prior authorization is a decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug or durable medical equipment is medically necessary. 

Certain medical services and prescription drugs require prior authorization in order to be considered for coverage under your plan. In those cases, your provider needs to obtain prior authorization from PacificSource before the treatment is provided. If prior authorization is not requested when required, and the services are not covered by your plan benefits, you may be held responsible for payment to your provider. 

Prior authorization is a service for you and your healthcare provider that helps:

• Determine insurance benefits and provider contract status 
• Optimize the quality of your care 
• Anticipate and plan for any additional services that might be needed 
• Facilitate timely payment of claims 
• Identify opportunities for PacificSource case management or disease management programs

You can search our Provider Authorization Grid by procedure name or billing code. 

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 are required for inpatient, residential, partial hospitalization, and intensive outpatient mental health and chemical dependency treatment.

When considering prior authorization requests, we review all pertinent information available and we may communicate with your healthcare provider if additional clinical information is needed. Our prior authorization guidelines are based on current medical evidence, clinical criteria, medical necessity, and evidence-based criteria, and are reviewed and updated as needed

Requests must be received in writing from the requesting 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 best determination.

We respond to prior authorization requests from healthcare providers within two business days.

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 in to InTouch, or by calling our Health Services Department at 888-691-8209; TTY 711.

To have your claim reconsidered for coverage, have your provider's office submit a retrospective prior authorization request. The provider should include the fully completed prior authorization request form along with related chart notes and/or an operative report to support the request. We will process the request within 30 days of receipt.

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, or population management basis, regardless of coverage determinations.
 

Usually, your provider or pharmacy will submit claims on your behalf. If you need to fill a covered prescription or see an out-of-network provider for a covered service and the provider is not submitting the claim on your behalf, you can submit the claim to us. You will need to submit a claim form and a copy of the provider’s itemized bill. The itemized bill needs to include:

• Patient's name 
• Date of Service (mm/dd/yyyy) 
• Procedure Code(s) 
• Diagnosis Code(s) – ICD Format 
• Healthcare professional’s full name, credentials, address, phone number, TIN, and NPI (if one is assigned) 
• Total charge for each service rendered 
• The date your prescription was filled or the service was provided 
• The medication name, strength, and quantity dispensed

If the required information is not received, it may delay the processing of your claim.

If your coverage is provided through your employer, please add your employer's name and group number (if known). If the treatment was for an accident, please include details.

• Mail your claim to PacificSource Health Plans, Claims Department, PO Box 7068, Springfield, OR 97475. 
• Or email:
  • medical and vision: CS@PacificSource.com
  • pharmacy: Pharmacy@PacificSource.com
  • dental: Dental@PacificSource.com
• Or fax:
  • medical and vision: 541-225-3632
  • pharmacy: 541-225-3665
  • dental: 541-225-3655  

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, not to exceed eighteen months from the date of service.

More information about filing claims can be found in your member handbook or policy. 

There is a 30-day grace period for payment of each monthly premium if the policyholder does not qualify for premium subsidy or tax credit. There is a three-month grace period for payment of each monthly premium if the policyholder is receiving premium subsidy or tax credit. The policy will expire at the end of the grace period or after PacificSource has notified the policyholder in writing at the last known address that premium is past due.

Coverage and all claim liability end on the last day of the last month that premiums were accepted by PacificSource. If we deposit funds remitted by the policyholder after the grace period, that action does not automatically constitute reinstatement of an expired policy. Enrollees who are receiving a subsidy will have coverage for all allowable claims for the first month of the three-month grace period. Subsequent claims in the second and third month of the grace period will be pended until payment is received. When a claim is pended, that means no payment will be made to your healthcare provider until the premium is paid in full. Once the past-due premium is paid in full, we will process all claims for covered services received during the second and third month of the grace period.

Coordination of benefits

In some cases, a company other than PacificSource is responsible for paying your claim, or paying it first (primary payer). If you or a dependent on your plan have coverage with another health plan, they may be considered the primary payer. This can be referred to as “double coverage.”  If another plan is primary, they would process and pay your claim first, then PacificSource would process the remainder of the claim according to your plan benefits. 

Third party liability

If there is a motor vehicle accident, workers' compensation claim, or homeowners/premise claim, it may be the responsibility of a different company. These are often referred to as third party liability claims. Sometimes, we may need more information for your claim. We may ask you to fill out a Medical Service Questionnaire form (also called an accident report form) before we can finish processing the claim.

If you end (terminate) your PacificSource coverage, please let us know the end date as soon as possible. If your coverage is through an employer group plan, your employer will notify us. 

Claims are only paid for services or prescriptions you receive after your coverage starts and before your coverage ends. We process and pay claims according to your plan benefits while you have PacificSource coverage. 

How Claims Can Be Affected

In some cases, claims may be denied retroactively, even after you have obtained services from the healthcare provider. This can happen if your coverage ends and we haven’t received a coverage termination notice in time. For example, you might have changed employers or decided to end your PacificSource plan and stopped paying your premium. 

• If we process and pay claims for services received after coverage ends, we will reprocess and deny the claim, and then ask for the paid amount to be refunded.
• If your premium payment is late, we may hold claim payments until after we receive the premium. If your coverage ends, we will deny claims for services you received or prescriptions you filled after the coverage end date.

You can avoid retroactive denials by paying your premiums on time and in full, and making sure you talk to your provider about whether the service performed is a covered benefit. You can also avoid retroactive denials by obtaining your medical services from an in-network provider.

Note: If you had coverage under a different insurance company health plan at the time of the service, you or your doctor can submit the claim to that insurance company. If you didn’t have any coverage, you are responsible for paying the full cost of the service or prescription.

Providing you with the best possible service is important to us. We understand that you may have questions or concerns about your benefits, eligibility, the quality of care you receive, or how we reached a claim determination or handled a claim. We aim to answer your questions promptly and give you clear, accurate answers.

If you have a question, concern, or complaint, please contact our Customer Service department. Many times our Customer Service staff can answer your question or resolve an issue to your satisfaction right away.

Customer Service staff is available 8:00 a.m. to 5:00 p.m., Monday through Friday: 

• Oregon: 541-684-5582 or 888-977-9299
• Idaho: 208-333-1596 or 800-688-5008
• Montana: 406-442-6589 or 877-590-1596
• TTY: 711
• En Español: 866-281-1464 
• Email: cs@pacificsource.com

If we are not able to resolve the issue, you may file a formal grievance or appeal in one of three ways. (See our Appeal Form PDF): 

• 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.

You may also file a complaint and review complaint history with your State Insurance Commissioner’s office by going to the following links:

• Oregon: DFR.Oregon.gov/help/complaints-licenses/Pages/file-complaint.aspx
• Idaho: DOI.Idaho.gov/consumer/complaint
• Montana: CSIMT.gov/insurance/complaints/
• Washington: Insurance.WA.gov/file-complaint-or-check-your-complaint-status

More detailed information about our grievance and appeals process is provided in your member handbook or policy.

If your dispute with PacificSource relates to an adverse benefit determination that a course or plan of treatment is not medically necessary; is experimental or investigational; is not an active course of treatment for purposes of continuity of care; nonformulary drug has been denied; or is not delivered in an appropriate healthcare setting and with the appropriate level of care, you or your authorized representative can request for us to submit the case for an external review by an impartial, third-party reviewer known as an independent review organization (IRO). We must follow the IRO’s decision. 

Your request for an independent review must be made within 180 days of the date of the second internal appeal response. External independent review is available at no cost to you, but is generally only available when coverage has been denied for the reasons stated above and only after all internal grievance levels are exhausted. The Plan will pay for any cost associated with the external independent review.

This information, along with additional information about appeal procedures, is available in your Member Handbook. To access your handbook, log in to InTouch, go to the Benefits menu option, and select What’s Covered. You’ll find links to your handbook and more benefit details on this page.

In the states of Montana, Oregon, or Washington, an IRO review may be requested by you or your authorized representative by mailing, calling, or faxing the request to:

PacificSource Health Plans
Attn: Appeals and Grievances
PO Box 7068
Springfield, OR 97475

Phone: 541-684-5201
TTY: 711. We accept all relay calls.
Fax: 541-225-3628

In the state of Idaho, an IRO review may be requested by you or your authorized representative by mailing, calling, or faxing the request to:

Idaho Department of Insurance
Attn: External Review
700 W State St., 3rd Floor
Boise, ID 83720-0043

Phone: 208-334-4250
Toll-free: 800-721-3272, TTY: 711
Fax: 208-334-4398

The privacy of your medical information is important to us. Learn more about our commitment to protect your personal health information in our Privacy Policy.

As you are using our websites, information we may collect is used only to confirm your identity and answer your questions, provide you with information about your policy, or provide you with information about our services. We will not sell your information or provide information to marketing organizations. Learn more in our Privacy Statement.
 

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 

If you are deaf, hard of hearing, or speech-impaired, please reach us using TTY: 711. We're available during our regular business hours of 8:00 a.m. to 5:00 p.m., Monday through Friday.

PacificSource is committed to providing you with the highest level of service in the industry. By respecting your rights and clearly explaining your responsibilities under your health plan, we will promote effective healthcare.

This information is also provided in your Member Handbook or policy.

Your rights as a member:

• You have a right to receive information about PacificSource, our services, our providers, and your rights and responsibilities. 
• You have a right to expect clear explanations of your plan benefits and exclusions. 
• You have a right to be treated with respect and dignity. 
• You have a right to impartial access to healthcare without regard to race, religion, gender, national origin, or disability. 
• You have a right to honest discussion of appropriate or medically necessary treatment options. You are entitled to discuss those options regardless of how much the treatment costs or if it is covered by this plan. 
• You have a right to the confidential protection of your medical records and personal information. 
• You have a right to voice complaints about PacificSource or the care you receive, and to appeal decisions you believe are wrong. 
• You have a right to participate with your healthcare provider in decision-making regarding your care. 
• You have a right to know why any tests, procedures, or treatments are performed and any risks involved. 
• You have a right to refuse treatment and be informed of any possible medical consequences. 
• You have a right to refuse to sign any consent form you do not fully understand, or cross out any part you do not want applied to your care. 
• You have a right to change your mind about treatment you previously agreed to. 
• You have a right to make recommendations regarding PacificSource Health Plans' member rights and responsibilities policy.

Your responsibilities as a member:

• You are responsible for reading your Member Handbook or policy and all other communications from PacificSource, and for understanding your plan's benefits. You are responsible for contacting PacificSource Customer Service if anything is unclear to you. 
• You are responsible for making sure your provider obtains preauthorization for any services that require it before you are treated. 
• You are responsible for providing PacificSource with all the information required to provide benefits under your plan. 
• You are responsible for giving your healthcare provider complete health information to help accurately diagnose and treat you. 
• You are responsible for telling your providers you are covered by PacificSource and showing your member ID when you receive care. 
• You are responsible for being on time for appointments, and calling your provider ahead of time if you need to cancel.
• You are responsible for any fees the provider charges for late cancellations or 'no shows.' 
• You are responsible for contacting PacificSource if you believe you are not receiving adequate care. 
• You are responsible to supply information to the extent possible that PacificSource needs in order to administer your benefits or your medical providers need in order to provide care.
• You are responsible to follow plans and instructions for care that you have agreed to with your doctors.
• You are responsible for understanding your health problems and participating in developing mutually agreed upon goals, to the degree possible.