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  • What is prior authorization or preauthorization?

    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:

    • 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

     

  • How will I know if my upcoming procedure requires prior authorization?

    You can search our (link is external)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.

     

  • Do I need a prior authorization or referral for mental healthcare?

    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.

     

  • How are prior authorization decisions made?

    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.

  • Can I call in a prior authorization request?

    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.

  • When can I expect my prior authorization to be completed?

    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.

  • How will I be notified of the decision?

    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 (link is external)InTouch, or by calling our Health Services Department at 888-691-8209.

  • What can I do if a claim isn't approved because prior authorization was not obtained?

    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.

  • What is the difference between UCR and the PacificSource allowable fee?

    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.

     

  • If I meet my out-of-pocket maximum, will I have to pay any further claims?

    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 888-977-9299orcs@pacificsource.com for more information on your plan’s out-of-pocket maximum provisions.

     

  • If I’m hurt in an auto accident, will PacificSource cover my medical expenses?

    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. 

  • What is covered under diabetic care?

    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.

  • What are my mental health insurance benefits?

    Specific mental health benefits vary and are determined by your insurance policy. Please refer to your benefit summary or Member Benefit Handbook—available through (link is external)InTouch for Members—or call our Customer Service staff at 888-977-9299. Mental healthcare may include:

    • Screening or diagnostic tests to identify a mental health problem
    • Hospital, residential, and outpatient care
    • Prescription drugs
    • Counseling or therapy for individuals, children, and families
    • Group counseling or therapy
  • I'm a new member with an ongoing health concern. How can I communicate my healthcare needs to PacificSource?

    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.

     

  • Can I remove the benefits I don’t use from my policy and pay a lower premium rate?

    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.

  • I’m planning a trip and need preventive immunizations before I travel. Will that be covered under my policy?

    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.

  • Are flu shots covered under my policy?

    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.

     

  • What is considered a medical emergency?

    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):

    • Unusual or heavy bleeding
    • Sudden abdominal or chest pains
    • Suspected heart attacks
    • Major traumatic injuries
    • Serious burns
    • Poisoning
    • Unconsciousness
    • Convulsions or seizures
    • Difficulty breathing
    • Sudden fevers
  • What is “medical necessity”?

    Medically necessary means those services and supplies required for diagnosis or treatment of illness or injury, and that in the judgment of PacificSource are:

    • Consistent with the symptoms or diagnosis and treatment of the condition
    • Consistent with generally accepted standards of good medical practice in the state of Oregon, or expert consensus physician opinion published in peer-reviewed medical literature, or the results of clinical outcome trials published in peer-reviewed medical literature
    • As likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any other service or supply, both as to the disease or injury involved and the patient’s overall health condition
    • Not for the convenience of the member or a provider of services or supplies
    • The least costly of the alternative services or supplies that can be safely provided 
    • When applied in a hospital inpatient setting, medically necessity further means that the services or supplies can’t be safely provided in other than a hospital inpatient setting without adversely affecting the patient’s condition or the quality of medical care rendered
  • What are my options if my coverage is ending?

    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.

  • Can my child stay on the policy during summer break from college?

    Yes, as long as the child remains unmarried and intends to return to college in the fall.

  • My child is finishing high school and doesn’t plan to go on to college. Can they stay on my policy?

    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.

  • My child is graduating from college. Can they stay on my policy?

    Yes. Adult children can now remain on their parents’ plan until age 26.

  • Can I keep my COBRA or other continuation coverage if I move out of state?

    Yes. Continuation coverage is not dependent on your state of residence.

  • What is case management? Who’s eligible?

    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:

    • Transplant
    • Chronic pain management
    • Extended hospital or skilled nursing care
    • Home medical services or equipment
    • Special needs children

    If you think you might benefit from case management, please contact our Health Services Department at 888-691-8209.

  • To what address should I mail my premium payment?

    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

     

  • My group health plan’s enrollment changed after you issued my bill. Can I adjust the premium accordingly and pay you the adjusted amount?

    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.

  • Is a premium charged for late enrollees during their six-month-eligibility waiting period?

    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.

  • What should I do if a former employee hasn’t paid their COBRA premium by the time I pay our PacificSource group premium?

    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.

  • I mailed the insurance premium for our group policy before the end of the coverage month, but our coverage was still terminated for nonpayment. Why?

    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.

     

  • If I have questions or concerns about my healthcare coverage, what are my rights as a PacificSource member?

    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

  • How does PacificSource handle grievances and appeals?

    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.

  • What is the difference between informal and formal review?

    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.

     

  • What is the difference between a grievance and an appeal?

    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.

     

  • How do I submit a grievance or appeal?

    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 Health Plans Appeal and Grievance Department, PO Box 7068, Springfield, OR 97475-0068; email newappeal@pacificsource.com; or fax your message to 541-322-6424.

     

  • If I need help filing a grievance or an appeal, can PacificSource help me?

    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.

  • How long does it take to resolve a grievance or appeal?

    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.

  • What if I’m not satisfied with the decision of my grievance or appeal?

    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.

     

  • Do you have a list of in-network or participating providers?

    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.

  • How do I know which insurance plan to select when I’m using your online Provider Directory?

    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 (link is external)InTouch for Members.

  • Can I see any provider I want?

    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 (link is external)InTouch for Members), or contact our Customer Service staff at 888-977-9299 or cs@pacificsource.com for coverage information.

  • My provider isn't on your list of in-network providers. How can I get him/her to join?

    You can use our Provider Nomination Form to ask your healthcare provider to consider joining the PacificSource network.

  • What happens if my healthcare provider stops participating in the PacificSource network while I’m still receiving treatment?

    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.

  • What is a referral?

    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.

  • What if I need medical care while I’m traveling out of state?

    When traveling outside Idaho, Montana, Oregon, and Washington, members can access in-network care nationally through our collaboration with Aetna Signature Administrators®. (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.

  • What if I need medical care while I’m out of the country?

    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.

  • How do I find an in-network dentist?

    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. 

  • How can I select the best type of mental health practitioner for my needs?

    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.

  • As an employer, am I obligated to add all new employees to our health plan?

    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.

  • How can I remove employees or dependents from coverage on our group health plan?

    You can remove members from your plan online using (link is external)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.

  • If an employee didn’t enroll in our group coverage when originally eligible, when can he come onto our policy?

    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.

     

  • If an employee didn’t enroll their dependents when he enrolled, when can their dependents be added to the group coverage?

    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.

General Information

What should I do if I need help when you’re closed?

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 (link is external)InTouch for Members, a secure member login site. If you prefer using your phone or tablet, download the free myPacificSource mobile app. 

General Information

Why does your application ask for my Social Security number?

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.
 

General Information

How can I get a copy of my policy?

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.

General Information

How can I get a summary of my plan benefits?

Your summary of benefits is available online at (link is external)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.

General Information

How can I get a new member ID card?

You can order a new member ID card any time by logging into (link is external)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.

General Information

Why aren’t all my covered family members listed on my ID card?

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 888-977-9299during business hours.

 

General Information

How can I update my mailing address, phone number, email address, or name?

You can update your contact information any time by logging into (link is external)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.

General Information

What information is available online to help me manage my coverage?

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, (link is external)register, (link is external)or log in now

General Information

What information is available online to help me manage my health?

As a PacificSource member, you can access CaféWell, an online health engagement portal. To get started, log into (link is external)InTouch. Under the Benefits menu, choose Wellness – CaféWell.

 

Visit CaféWell to:

  • Complete the health assessment to identify your potential health risks.
  • Get your health and wellness questions answered by an expert health coach.
  • Connect with family, friends, and others with similar health goals.
  • Access helpful tips and articles on health and wellness.

General Information

What language assistance do you offer for members?

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

General Information

What is the difference between an FSA and an HRA?

A Flexible Spending Account (FSA) allows you to pay for eligible expenses with pretax dollars that you contribute via paycheck deductions.

A Health Reimbursement Arrangement (HRA) is funded by your employer to help reimburse you for eligible health expenses incurred by you or your family (for accounts that include your family).

Learn more by downloading our FSA Participant Guide.

FSA Participant Guide

FSA Participant Guide (en español)

General Information

What are your business hours?

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 atcs@pacificsource.com.

Preauthorization

What is prior authorization or preauthorization?

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:

  • 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

 

Preauthorization

How will I know if my upcoming procedure requires prior authorization?

You can search our (link is external)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.

 

Preauthorization

Do I need a prior authorization or referral for mental healthcare?

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.

 

Preauthorization

How are prior authorization decisions made?

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.

Preauthorization

Can I call in a prior authorization request?

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.

Preauthorization

When can I expect my prior authorization to be completed?

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.

Preauthorization

How will I be notified of the decision?

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 (link is external)InTouch, or by calling our Health Services Department at 888-691-8209.

Preauthorization

What can I do if a claim isn't approved because prior authorization was not obtained?

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.

Benefits & Coverage

What is the difference between UCR and the PacificSource allowable fee?

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.

 

Benefits & Coverage

If I meet my out-of-pocket maximum, will I have to pay any further claims?

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 888-977-9299orcs@pacificsource.com for more information on your plan’s out-of-pocket maximum provisions.

 

Benefits & Coverage

If I’m hurt in an auto accident, will PacificSource cover my medical expenses?

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. 

Benefits & Coverage

What is covered under diabetic care?

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.

Benefits & Coverage

What are my mental health insurance benefits?

Specific mental health benefits vary and are determined by your insurance policy. Please refer to your benefit summary or Member Benefit Handbook—available through (link is external)InTouch for Members—or call our Customer Service staff at 888-977-9299. Mental healthcare may include:

  • Screening or diagnostic tests to identify a mental health problem
  • Hospital, residential, and outpatient care
  • Prescription drugs
  • Counseling or therapy for individuals, children, and families
  • Group counseling or therapy

Benefits & Coverage

I'm a new member with an ongoing health concern. How can I communicate my healthcare needs to PacificSource?

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.

 

Benefits & Coverage

Can I remove the benefits I don’t use from my policy and pay a lower premium rate?

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.

Benefits & Coverage

I’m planning a trip and need preventive immunizations before I travel. Will that be covered under my policy?

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.

Benefits & Coverage

Are flu shots covered under my policy?

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.

 

Benefits & Coverage

What is considered a medical emergency?

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):

  • Unusual or heavy bleeding
  • Sudden abdominal or chest pains
  • Suspected heart attacks
  • Major traumatic injuries
  • Serious burns
  • Poisoning
  • Unconsciousness
  • Convulsions or seizures
  • Difficulty breathing
  • Sudden fevers

Benefits & Coverage

What is “medical necessity”?

Medically necessary means those services and supplies required for diagnosis or treatment of illness or injury, and that in the judgment of PacificSource are:

  • Consistent with the symptoms or diagnosis and treatment of the condition
  • Consistent with generally accepted standards of good medical practice in the state of Oregon, or expert consensus physician opinion published in peer-reviewed medical literature, or the results of clinical outcome trials published in peer-reviewed medical literature
  • As likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any other service or supply, both as to the disease or injury involved and the patient’s overall health condition
  • Not for the convenience of the member or a provider of services or supplies
  • The least costly of the alternative services or supplies that can be safely provided 
  • When applied in a hospital inpatient setting, medically necessity further means that the services or supplies can’t be safely provided in other than a hospital inpatient setting without adversely affecting the patient’s condition or the quality of medical care rendered

Eligibility

What are my options if my coverage is ending?

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.

Eligibility

Can my child stay on the policy during summer break from college?

Yes, as long as the child remains unmarried and intends to return to college in the fall.

Eligibility

My child is finishing high school and doesn’t plan to go on to college. Can they stay on my policy?

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.

Eligibility

My child is graduating from college. Can they stay on my policy?

Yes. Adult children can now remain on their parents’ plan until age 26.

Eligibility

Can I keep my COBRA or other continuation coverage if I move out of state?

Yes. Continuation coverage is not dependent on your state of residence.

Eligibility

What is case management? Who’s eligible?

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:

  • Transplant
  • Chronic pain management
  • Extended hospital or skilled nursing care
  • Home medical services or equipment
  • Special needs children

If you think you might benefit from case management, please contact our Health Services Department at 888-691-8209.

Premiums

To what address should I mail my premium payment?

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

 

Premiums

My group health plan’s enrollment changed after you issued my bill. Can I adjust the premium accordingly and pay you the adjusted amount?

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.

Premiums

Is a premium charged for late enrollees during their six-month-eligibility waiting period?

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.

Premiums

What should I do if a former employee hasn’t paid their COBRA premium by the time I pay our PacificSource group premium?

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.

Premiums

I mailed the insurance premium for our group policy before the end of the coverage month, but our coverage was still terminated for nonpayment. Why?

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.

 

Grievances & Appeals

If I have questions or concerns about my healthcare coverage, what are my rights as a PacificSource member?

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

Grievances & Appeals

How does PacificSource handle grievances and appeals?

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.

Grievances & Appeals

What is the difference between informal and formal review?

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.

 

Grievances & Appeals

What is the difference between a grievance and an appeal?

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.

 

Grievances & Appeals

How do I submit a grievance or appeal?

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 Health Plans Appeal and Grievance Department, PO Box 7068, Springfield, OR 97475-0068; email newappeal@pacificsource.com; or fax your message to 541-322-6424.

 

Grievances & Appeals

If I need help filing a grievance or an appeal, can PacificSource help me?

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.

Grievances & Appeals

How long does it take to resolve a grievance or appeal?

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.

Grievances & Appeals

What if I’m not satisfied with the decision of my grievance or appeal?

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.

 

Providers & Referrals

Do you have a list of in-network or participating providers?

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.

Providers & Referrals

How do I know which insurance plan to select when I’m using your online Provider Directory?

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 (link is external)InTouch for Members.

Providers & Referrals

Can I see any provider I want?

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 (link is external)InTouch for Members), or contact our Customer Service staff at 888-977-9299 or cs@pacificsource.com for coverage information.

Providers & Referrals

My provider isn't on your list of in-network providers. How can I get him/her to join?

You can use our Provider Nomination Form to ask your healthcare provider to consider joining the PacificSource network.

Providers & Referrals

What happens if my healthcare provider stops participating in the PacificSource network while I’m still receiving treatment?

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.

Providers & Referrals

What is a referral?

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.

Providers & Referrals

What if I need medical care while I’m traveling out of state?

When traveling outside Idaho, Montana, Oregon, and Washington, members can access in-network care nationally through our collaboration with Aetna Signature Administrators®. (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.

Providers & Referrals

What if I need medical care while I’m out of the country?

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.

Providers & Referrals

How do I find an in-network dentist?

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. 

Providers & Referrals

How can I select the best type of mental health practitioner for my needs?

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.

Info for Employers

As an employer, am I obligated to add all new employees to our health plan?

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.

Info for Employers

How can I remove employees or dependents from coverage on our group health plan?

You can remove members from your plan online using (link is external)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.

Info for Employers

If an employee didn’t enroll in our group coverage when originally eligible, when can he come onto our policy?

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.

 

Info for Employers

If an employee didn’t enroll their dependents when he enrolled, when can their dependents be added to the group coverage?

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.

InTouch Help (general)

Why is the "Forgot My Password" link not working?

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.

InTouch Help (general)

What should I do if I'm returned to the login page after I submit answers to the hint questions?

This can occur if punctuation or special characters are used in the hint answers. Please try again without any punctuation or special characters.

InTouch Help (general)

Are the answers to hint questions case-sensitive?

No, they are not case-sensitive.

InTouch Help (general)

Why am I having difficulty logging into InTouch for Members?

  • You might be following an outdated link or bookmark to the login page. Try logging in by going directly to (link is external)https://intouch.pacificsource.com/members/Account/SignIn
  • Check that you are entering the same member number and password that you used when you originally registered. If you have a newly issued member ID card, the number may be slightly different than the one you originally used to register.
  • If you haven’t logged in for more than two years, your registration may have been automatically disabled as a security precaution.

InTouch Help (general)

What if I still have questions or issues with InTouch for Members?

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

InTouch Help (general)

What if I still have questions or issues with InTouch for Agents?

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 Usform. 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.

InTouch Help (general)

What if I still have questions or issues with InTouch for Providers?

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.

InTouch for Employers

Where can I find member benefit summaries from within InTouch for Employers?

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.

InTouch for Employers

Can my bill be accessed or paid online?

Not at this time. We do offer premium payment by electronic funds transfer, however. Contact your PacificSource Membership Representative for more information.

InTouch for Employers

If a member's group number is changing, does that change their InTouch registration details?

Yes. The member must register for (link is external)InTouch for Members using the new group number, even if the new number is not yet in effect.

InTouch for Employers

Can I change a member's last name using online enrollment in InTouch for Employers?

No. To change a subscriber's last name, please contact your PacificSource Membership Representative.

InTouch for Employers

Can I change a dependent's date of birth using online enrollment in InTouch for Employers?

No. To change a dependent's date of birth, please contact your PacificSource Membership Representative.

InTouch for Employers

Can I update a subscriber's mailing address using online enrollment in InTouch for Employers?

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. 

InTouch for Employers

How do I enter the city, state, and county fields using online enrollment in InTouch for Employers?

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.

InTouch for Employers

Why can’t I view plans on the Plan Selection screen using online enrollment in InTouch for Employers?

A few potential causes:

  • Verify that you’re using a valid subgroup and class rather than one that would not be current at the time of the employee’s date of hire or effective date. (InTouch currently assumes a default class of 1001, so be sure to change this if that is not the subscriber's correct class.)
  • If the effective date of the correct class comes after the member's hire date (regardless of the member's effective date), the class will not be available for you to enroll online. If that’s the case, please send the subscriber's application to your Membership Representativefor manual entry.
  • If both of the above have been ruled out, 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’re using, and a description of the error.

InTouch for Employers

I'm using online enrollment in InTouch for Employers, and after selecting a plan, I'm told that I need to select a plan. Why?

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.

InTouch for Employers

When I terminate a subscriber using online enrollment in InTouch for Employers, do I also need to terminate all dependents on the policy?

No. When the subscriber is terminated, all dependents are automatically terminated as well.

InTouch for Employers

How do I enter information about other or prior coverage using online enrollment in InTouch for Employers?

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.

InTouch for Employers

What if I still have unanswered questions or issues with InTouch for Employers?

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.

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