Frequently Asked Questions

Looking for an answer? You can either perform a Quick Search, or browse by topic by selecting a heading below. Use the "Back" button on your browser to return to the table of contents.

 

General Information

 

Prescription Drugs

 

Do you have a list of preferred drugs?

Does the preferred drug list change?

The medication I take used to be on my plan’s preferred drug list, but now it’s not. What does that mean for me?

Why are some drugs excluded from the PDL or VDL?

Who determines if a drug is included on the PDL or VDL?

How do I know what my prescription copayment will be?

How can I keep my out-of-pocket costs for prescriptions to a minimum?

Where can I fill my prescription?

How do I know if my medication has a generic version?

Why should I take generic drugs?

How will I know if my medication requires preauthorization?

What should I do if my medication requires preauthorization?

What does "step therapy" mean?

What does it mean if my drug has a quantity limit?

How often can I refill my prescription?

What if I’ll need a refill sooner because my doctor increased my dosage?

What if I’m going on vacation and need to refill my prescription early, before I go?

How do I use my mail-order benefit?

How long does mail-order service take?

How are injectable medications covered?

How are compounded prescriptions covered?

Is Sudafed or any product containing pseudoephedrine covered under my pharmacy benefit?

When pharmacies like Target, Wal-Mart, and Fred Meyer advertise low fixed prices on prescription drugs, can I take advantage of those offers?

Preauthorization

 

Referrals

 

Plan Benefits and Coverage

 

Eligibility for Coverage

 

Premium Payment

 

Participating Providers

 

Grievances and Appeals

 

InTouch for Administrators

 

Why am I having difficulty logging into InTouch for Administrators?

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

Are the answers to hint questions case-sensitive?

Why am I prompted to change my password? I use the site frequently.

How can I set my computer to accept pop-up windows from PacificSource?

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

Can my bill be accessed, viewed, or paid online?

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

Can I change a subscriber's last name using online enrollment in InTouch for Administrators?

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

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

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

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

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

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

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

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

InTouch for Members

 

InTouch for Agents

 

InTouch for Providers

 

General Information

What are your 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.

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

If you have a true medical emergency, always go directly to the nearest emergency room or call 911 for help. In other cases, you’re welcome to use the Contact Us form to send us an inquiry online and we’ll respond the next business day. You can also access personalized information about your PacificSource coverage online 24/7 through InTouch for Members. Register or log in now.

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). Please be assured that we have sufficient security procedures in place to protect against inappropriate release of that 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: phone (888) 684-5585 or e-mail individual@pacificsource.com.

How can I get a summary of my plan benefits?

Your summary of benefits is available online in InTouch for Members, our secure member Web site. Register or log in now. If you’re covered under a group health 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.

How can I get a new member ID card?

You can order a new member ID card any time by logging into InTouch for Members, our secure member Web site. Register or log in now. 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.

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) 977-9299.

How can I update my mailing address, phone number, e-mail address, or name?

You can update your contact information any time by logging into InTouch for Members, our secure member Web site. Register or log in now. 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.

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

InTouch for Members is our secure Web site where you can track your claims, deductibles, out-of-pocket maximums, preauthorizations, referrals, and more. Learn moreregister, or log in now.

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

Health Manager is an online health and wellness center with personalized information, health risk assessments, and tools to help you make the most of your health. You’ll find Health Manager within InTouch for Members area. Register or log in now

What Spanish language assistance do you offer for members?

Several of our Customer Service team members are fluent in Spanish. For Spanish language assistance, you may call (541) 684-5456 or (800) 624-6052, ext. 5456. We can also provide Spanish translations of all our Member Benefit Summaries and most forms and materials upon request.

Prescription Drugs

Do you have a list of preferred drugs?

Your prescription plan uses one of two PacificSource drug lists: our PDL (Preferred Drug List) or our VDL (Value Drug List). Your Summary of Benefits—available online through your InTouch account—will tell you which list applies to your plan. Both lists are available in our online drug list. They are a guide to excellent values on brand name prescription drugs. Your drug list will help your doctor identify medications that can provide the best clinical results at the lowest cost.

Does the preferred drug list change?

Yes, our PDL and VDL change as new drugs constantly enter the market and brand name drugs become available generically. These lists are updated each month, and you can always find the current PDL and VDL on our online drug list page. It's a good idea to check the list before filling your prescription to make sure your medication is still preferred.

The medication I take used to be on my plan’s preferred drug list, but now it’s not. What does that mean for me?

When a medication drops off the PDL or VDL, it’s because there is now a generic equivalent or another therapy that provides better clinical and economic benefits. Check with your doctor to see if there’s a generic or preferred brand medication that would work for you. If not, you'll still be able to access the medication at your plan's Tier 3 benefit level. 

Why are some drugs excluded from the PDL or VDL?

When drugs are not granted preferred status, it is due to one or more of the following reasons:

  • There is a federally approved generic equivalent.
  • There are many other drugs available to treat the same condition, and one drug is proven less safe or more expensive and offers no particular medical advantage over others.
  • A new product offers no particular advantage over existing products used to treat the same condition.

Who determines if a drug is included on the PDL or VDL?

A committee made up of physicians and pharmacists reviews drug therapies to determine if they are granted preferred status. These committee members do not have a direct financial interest in the decision, and are generally very sensitive to the needs of patients and their doctors.

How do I know what my prescription copayment will be?

Your copayment depends on your prescription drug plan design. Your Summary of Benefits (available online through your InTouch account) will tell you whether your plan uses a Preferred Drug List (PDL) or Value Drug List (VDL), and what your copays are. You're also welcome to call our Customer Service staff at (888) 977-9299 to check on your drug copayment.

  • All generic prescription drugs are available for your lowest (Tier 1) copay.
  • Brand name prescription drugs listed on your PDL or VDL are available for your Tier 2 copay.
  • Brand name prescription drugs not on your PDL or VDL are available for you highest (Tier 3) copay.

How can I keep my out-of-pocket costs for prescriptions to a minimum?

  • Take the PDL or VDL with you to office visits with your healthcare provider.
  • Ask your provider to prescribe generic products whenever possible.
  • Ask your pharmacist to fill your prescription with a generic product if possible.
  • If a medication you need isn’t available generically, or is not on your plan’s drug list, ask your provider to choose a brand name product that is on your PDL or VDL.
  • Explain to your provider that keeping your copayments as low as possible is important to you, as long as the medication is right for your condition.

Where can I fill my prescription?

  • Retail: PacificSource contracts with the CVS Caremark® retail pharmacy network. The retail pharmacy network includes most pharmacy chains and many independent pharmacies throughout the U.S., including all Albertsons, Bi-Mart, Costco, CVS, Fred Meyer, Hi-School, Kmart, Rite Aid, Safeway, Sav-on, Shopko, Target, The Medicine Shoppe, Walgreens and Wal-Mart pharmacies. To learn whether a specific pharmacy is participating, you can contact PacificSource Pharmacy Services at pharmacy@pacificsource.com or (800) 624-6052, ext. 3784.
  • Mail order: You also have access to two mail order pharmacy services: CVS Caremark and Wellpartner.
  • Injectables: Specialty pharmacy medications like injectable and biotech drugs must be obtained through Caremark Specialty Pharmacy Services. These medications may have a higher copay or coinsurance than other prescriptions. Learn more about our specialty pharmacy program, or contact PacificSource Pharmacy Services at pharmacy@pacificsource.com or (800) 624-6052, ext. 3784 with questions. 

How do I know if my medication has a generic version?

Ask your pharmacist if there's a generic version available. If you are already taking a particular medication, the generic name should be listed on the label for that medication, even if you were prescribed the brand name.

Why should I take generic drugs?

Generic drugs have the same active ingredients as their brand name counterparts. The U.S. Food and Drug Administration (FDA) requires all drug manufacturers to meet the same strict production process and control standards. Therefore, using generics is a simple and safe alternative to help reduce your prescription costs. Generics offer the best value, and your plan encourages their use whenever possible.

How will I know if my medication requires preauthorization?

Drugs that require preauthorization are listed on our PacificSource Drug List under Preauthorization (PA).

What should I do if my medication requires preauthorization?

If your medication requires preauthorization, talk with your medical provider as soon as possible about the prescribed medication and alternative options. If your physician decides to request preauthorization, he or she may fax our completed Preauthorization/Medication Exception Request Form to (541) 225-3665 or phone us at (800) 624-6052, ext. 3784 if the matter is urgent. Preauthorization requests must come directly from the medical provider, not the patient.

If preauthorization criteria are met, we will approve coverage of the drug subject to your plan’s applicable copayment or coinsurance. If the preauthorization request is not approved, the drug will not be covered by your plan. In that case, if you decide to purchase the medication, you will be responsible for the total cost unless otherwise noted in the PDL or VDL. Be sure to show your PacificSource ID card at the pharmacy even if the medication isn't covered by your plan. Showing your ID card will allow you to access our prescription discount program.

What does "step therapy" mean?

Step therapy is a program that requires you to try a lower-cost alternative medication before using a more expensive medication. Certain medications are subject to step therapy under your PacificSource prescription drug benefits. Your PacificSource plan will cover step therapy medications only after you have tried specific, less expensive medications in the same therapeutic class.

If you have questions about coverage of step therapy medications, contact our Pharmacy Services Department at (541) 225-3784 or (800) 624-6052, ext. 3784, or use our online Contact Us form.

What does it mean if my drug has a quantity limit?

For some drugs, there is a limitation on the amount of medication you can receive within a specific period. If your medication has a quantity limit and you’ve been prescribed a higher dose, your physician can request preauthorization to allow multiple refills in the specific period. See the previous preauthorization question for more information.

How often can I refill my prescription?

  • Prescriptions filled at retail pharmacies can be refilled when 75 percent of the medication has been used according to the directions.
  • Prescriptions filled at mail order can be refilled when 67 percent has been used according to the directions.

What if I’ll need a refill sooner because my doctor increased my dosage?

If your physician has increased your dose, he or she must notify your pharmacy of the change in directions. Your pharmacy may then contact us to request an override for the early refill.

What if I’m going on vacation and need to refill my prescription early, before I go?

Ask your pharmacy to contact us to request a vacation override allowing an early refill. If you’re covered under a PacificSource group plan, we can allow an early refill for up to a 90 day supply depending on the duration of your trip. If you’re covered under an individual plan, we can allow you to refill a 30-day supply prior to your trip.

How do I use my mail order benefit?

We offer you a choice of two mail order pharmacy services: CVS Caremark and Wellpartner. To take advantage either service:

  • Contact PacificSource Pharmacy Services at pharmacy@pacificsource.com or (800) 624-6052, ext. 3784 to verify that the medication is eligible for mail order and learn what your copay will be.
  • Contact your healthcare provider to request a new written prescription for the medication, allowing a 90-day supply with each refill.
  • Register as a new customer with either CVS Caremark or Wellpartner, and send them your prescription with your initial order. You should allow two weeks for delivery of the first order.

You can reach CVS Caremark customer service staff at (866) 329-3051, or Wellpartner at (877) 935-5797.

How long does mail order service take?

You should allow two weeks for delivery of your first shipment via mail order. After that, refills are typically received within seven days of your order.

How are injectable medications covered?

Specific injectable medications, listed on our PacificSource Drug List under Specialty Drug (SP), are covered through your prescription drug benefit, provided your plan includes coverage for specialty pharmacy products. These products must be obtained through Caremark Specialty Pharmacy and may be subject to a higher copayment or coinsurance. Other injectable medications are excluded from the pharmacy benefit but may be covered under your plan’s medical benefits. Please contact PacificSource Pharmacy Services at pharmacy@pacificsource.com or (800) 624-6052, ext. 3784 so we can help you obtain your injectable medication.

How are compounded prescriptions covered?

Compounded prescriptions are subject to your pharmacy plan’s Tier 3 copayment. Because compounding pharmacies can be difficult to find, you’re welcome to contact PacificSource Pharmacy Services at pharmacy@pacificsource.com or (800) 624-6052, ext. 3784 for help finding one that can prepare your medication. You may use a nonparticipating compounding pharmacy and receive your plan’s Tier 3 benefits only if no participating pharmacy is available in the area where you live. If you fill your compounded prescriptions through a mail order service, it must be a participating pharmacy. You’ll need to pay for your compounded prescription when it’s filled and send your receipts to us for reimbursement, however. You may mail your reimbursement request to us at PacificSource, Attn: Pharmacy Claims, PO Box 7068, Springfield, OR 97475, or fax it to (541) 225-3665.

To find a participating pharmacy, please see the Where can I fill my prescription? section on this page.

Is Sudafed or any product containing pseudoephedrine covered under my pharmacy benefit?

No. Although these medications require a prescription in some states, your pharmacy benefit does not cover any drug for which federal law does not require a prescription. The over-the-counter therapeutic equivalent for Sudafed is Sudafed PE, and the over-the-counter therapeutic equivalent for Claritin-D is loratadine with Sudafed PE.

When pharmacies like Target, Wal-Mart, and Fred Meyer advertise low fixed prices on prescription drugs, can I take advantage of those offers?

Those retail programs offer consumers another low-cost prescription option and you are welcome to take advantage of them. To be sure you get the best available price, be sure you always show your PacificSource ID card at the pharmacy. The pharmacy will then process your prescription under the lowest available price, whether it's their promotional price, your plan's copayment, or our contracted rate.

Preauthorization

What is preauthorization?

Preauthorization is prospective review of a proposed healthcare treatment to determine availability of insurance benefits, medical necessity, and appropriateness. Sometimes it also includes assessment of the level of care and treatment setting.

Certain medical services and prescription drugs require preauthorization in order to be considered for coverage under your plan. In those cases, your provider is to obtain preauthorization from PacificSource before the treatment is provided. Failure to preauthorize when required may result in you being held responsible for payment to your provider if the services aren’t covered by your plan.

Preauthorization 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 preauthorization?

You’ll find an up-to-date listing of the types of services that require preauthorization on our Web site. If your procedure isn’t specifically listed but might fall under one of the broad categories on our preauthorization list—such as experimental or investigational procedures—it will require further inquiry. PacificSource Customer Service can verify whether a procedure requires preauthorization if we have your procedure’s billing code. Ask your provider to call us to check on preauthorization.

Do I need a preauthorization or referral for mental health care?

  • Outpatient mental health and chemical dependency services do not require preauthorization; 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.
  • Preauthorization and concurrent review is required for inpatient, residential, partial hospitalization, and intensive outpatient mental health and chemical dependency treatment.

How are preauthorization decisions made?

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

Can I call in a preauthorization request?

Requests must be received in writing from the requesting physician or healthcare provider. The preauthorization request form must be completed in full before we can begin the preuathorization process. We may require related chart notes and/or clinical information to make our best determination.

When can I expect my preauthorization to be completed?

We respond to preauthorization requests from healthcare providers within two business days. Requests received after 3:00 p.m. are processed the following business day.

How will I be notified of the decision?

As soon as a preauthorization 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 preauthorization request by logging into InTouch, or by calling our Health Services Department at (888) 691-8209.

What should I do if I have a claim that wasn't approved for payment due to “Preauthorization Required?”

To have your claim reconsidered for coverage, have your provider’s office submit a retrospective preauthorization request. The provider should include the fully completed medical preauthorization 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.

Referrals

What is a referral?

A referral is a feature of managed care health plans. It is authorization for you to see a medical provider other than your primary care practitioner (PCP) and receive your plan’s highest level of benefits. When appropriate, your PCP will request a referral from PacificSource on your behalf. Referrals are only required if you are covered under a PacificSource Prime plan.

Does my plan require referrals?

Referrals are only required if you are covered under a PacificSource Prime plan. You'll find your plan type on your PacificSource ID card, or by logging into InTouch for Members and looking at the Medical Plan Info section.

How will I be notified of the decision?

As soon as a referral determination is made, we send notice of the decision to the member, PCP, and specialist. You and your providers can also check the status of your referral request by logging into InTouch, or by calling our Health Services Department at (888) 691-8209.

If I’m covered under a PacificSource Prime plan, do I need a referral for all services other than those provided by my PCP?

There are a few exceptions to the referral requirement. You do not need a referral from your PCP for:

  • Routine vision services
  • Your annual women’s exam
  • Maternity care
  • Urgent care
  • Emergency care

My PCP referred me to a specialist, and now the specialist wants to refer me to someone else. What needs to happen?

If you’re covered under a PacificSource Prime plan, your PCP is responsible for coordinating all of your healthcare, including referral requests. The specialist who you saw must contact your PCP and recommend referral to the other practitioner. Your PCP will then contact PacificSource to request referral to the new practitioner.

How can I extend the dates for my referral in order to continue seeing the practitioner?

If you’re covered under a PacificSource Prime plan, your PCP is responsible for coordinating all of your healthcare. If your PCP feels you need continued treatment by another practitioner, he or she can request another referral by submitting a new Referral Request form, along with your chart notes, to our Health Services Department.

Plan Benefits and Coverage

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

UCR—or “usual, customary, and reasonable”—usually applies to services of nonparticipating or noncontracted providers. It’s the fee allowance we use to calculate benefits for dental providers and nonparticipating medical providers.

The PacificSource allowable fee applies to services of contracted participating 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 participating providers for the rest of the plan year. However, some plans have specific services that don’t apply to the out-of-pocket maximum, and/or services for which you continue to have a cost share even after your out-of-pocket maximum is met. Refer to your Summary of Benefits or contact PacificSource Customer Service at (888) 977-9299, or by e-mail at cs@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. Don’t worry, though—our Third Party Recovery Department will work with you to help ensure that your expenses are covered. Learn more about how third party recovery works.

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. Contact our Customer Service staff at (888) 977-9299 for details of your coverage.

What is covered under mental health care?

Specific mental health benefits vary and are determined by your insurance policy. Please refer to your benefit summary or Member Benefit Handbook – available through InTouch for Members - or call our Customer Service staff at (888) 977-9299 for details of your coverage. Mental health care 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. This form 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. Services well suited to care coordination include 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 phone call from a Health Services Representative. If appropriate, we’ll then assign a Nurse Case Manager to work with you during your transition to PacificSource.

What is case management?

Case management is a service available to all PacificSource members who have complex or chronic medical conditions and require support to manage their healthcare needs. It is a service aimed at improving health outcomes and quality of life 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, you’re welcome to contact our Health Services Department at (888) 691-8209.

Will my PacificSource coverage help me quit smoking?

Yes. The Quit for Life program includes one-on-one support and nicotine replacement therapy to help you give up tobacco for good.

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

No, we cannot 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 cover them.

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

Probably not. Immunizations for the purpose of travel 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. You’re welcome to contact PacificSource Customer Service at (888) 977-9299, or by e-mail at cs@pacificsource.com if you think your employer may have made an exception allowing this coverage.

Are flu shots covered under my policy?

How are flu vaccines covered under my medical benefits?

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.

  • County Health Departments: Covered at the participating provider benefit level, applicable deductibles and/or copayments will apply.
  • Physician’s Office: Covered subject to participating and nonparticipating provider provisions. Applicable deductibles, coinsurance, and maximum allowances will apply.

Note: As part of healthcare reform, deductibles and coinsurance will be waived for participating providers as policyholders renew on or after September 23, 2010 (grandfathered plans excluded). Please check with your employer to see if this applies to your plan.

How are flu vaccines covered under my pharmacy benefits?  

If your plan has a pharmacy benefit, you can obtain a flu vaccine shot from our participating flu shot pharmacy network. (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. 

What is considered a medical emergency?

An emergency medical condition is an injury or sudden illness, including severe pain, so severe that a prudent layperson with an average knowledge of health and medicine would expect that failure to receive immediate medical attention would risk seriously damaging the health of a person (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 that are 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 specifically applied to a hospital inpatient, it further means that the services or supplies cannot 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 for Coverage

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 individual@pacificsource.com or (888) 684-5585.

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 he/she stay on my policy?

If a dependent child isn’t enrolled in college, they can stay on your policy until age 19. Their coverage will automatically end on the last day of the month in which they turn 19.

My child is graduating from college. Can he/she stay on my policy?

Each employer’s group policy has specific eligibility rules for dependent children. Under most group policies, dependent children who are full-time students can remain covered until they reach age 23 or are no longer a full-time student, whichever occurs first. Each employer’s eligibility rules can vary, so check with your employer or see your Member Benefit Handbook for details about your policy’s dependent eligibility criteria.

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

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

As the employer, am I obligated to add all new employees to the 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 are 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 InTouch for Plan Administrators portal. Register or log in now. You can also contact your Membership Service Representative in writing (via fax, mail, or e-mail) 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 his dependents when he enrolled, when can his dependents be added to the group coverage?

Dependents can be added to the 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 be subject to a six-month wait—beginning the first day of the month after we receive the enrollment application—before coverage can begin.

Premium Payment

To what address should I mail my premium payment?

  • Individual policy premium should be mailed to: PO Box 3389, Portland, OR 97208
  • Group policy premium should be mailed to: PO Box 4210, Portland, OR 97208-4210

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, we must ask that you 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 both you and us reconcile your monthly premium.

Is 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. They will be included on your bill once the waiting period is satisfied and they are eligible for coverage.

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:

  • 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 month’s billing, provided no claims have been reimbursed for that month.
  • Terminate the former employee’s coverage back to the last day of the last month for which 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 and 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 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 premium was received.

Group policy premium is always 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.

Participating Providers

Do you have a list of 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.

ID Card for Provider Directory PageHow 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 InTouch for Members. Register or log in now.

Can I see any provider I want?

Yes, although you’ll receive your plan’s highest level of benefits when you use participating providers. Unless it’s a medical emergency, your benefits are lower when you seek treatment from a nonparticipating provider. If you’re on a PacificSource Prime plan, you also need a referral from your PCP to get the highest level of benefits. See your plan’s Summary of Benefits (available in InTouch for Members—register or log in now), or contact our Customer Service staff at (888) 977-9299 or cs@pacificsource.com for specific information on your coverage for nonparticipating providers.

My provider isn't on your list of participating 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 should it happen, we’ll ensure that you have 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 participating 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 participating provider when appropriate. If you choose to continue seeing the provider, your plan's nonparticipating provider benefit level will then apply.

What does “Network Not Available” mean?

Network Not Available (NNA) means a member does not have reasonable geographic access, as determined by PacificSource, to a contracted participating provider for a medical service or supply. In these cases, we may make certain exceptions to a plan’s participating/nonparticipating benefits. Contact Customer Service at (888) 977-9299, or by e-mail at cs@pacificsource.com if you think this may apply to your situation.

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

If you live or travel outside the PacificSource network's service area, you have access to our contracted nationwide provider network, The First Health Network.

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

Your plan includes worldwide coverage. Learn more about how your benefits apply for international travel.

How do I find a participating dentist?

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.

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 participating providers.

The providers listed below are those trained in different areas of mental health care:

  • 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 health care 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 have 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.

Grievances and 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.

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 (typically when it’s formally written that way), we follow what’s called a formal review to determine how it can be resolved. The form your communication takes—written or verbal—has a strong effect on how it’s handled by us.

What’s 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 frequently related to 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 requires us to follow a four-part system to appropriately 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’s 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 by phone at (888) 977-9299, or by e-mail at cs@pacificsource.com.

Otherwise, you may file a grievance or appeal:

    • Write to PacificSource, Attn: Grievance Review, PO Box 7068, Springfield, OR 97475-0068;
    • Email lc@pacificsource.com, with “Grievance” as the subject; or
    • Fax your message to (541) 225-3628.
     

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 call our Customer Service Department. We will help you through the grievance 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, and within seven days we’ll send you an acknowledgement that the 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, and 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 PacificSource makes on 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.

InTouch for Employers

Why am I having difficulty logging into InTouch for Employers?

You might be following an outdated link or bookmark to the login page. Try logging in by going directly to https://intouch.pacificsource.com/SSO/SSOLogin.aspx  

What do 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 and leave out any punctuation and special characters.

Are the answers to hint questions case-sensitive?

No, they are not case-sensitive.

Why am I prompted to change my password? I use the site frequently.

All InTouch users are required to change their passwords every 90 days to maintain security standards and to comply with current HIPAA regulations.

How can I set my computer to accept pop-up windows from PacificSource?

Choose your browser to view instructions on managing pop-ups:

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.

Can my bill be accessed, viewed, 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.

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

Yes; the member must register for InTouch for Members using the new group number, even if the new number is not yet in effect.

Can I change a subscriber's last name using online enrollment in InTouch for Administrators?

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

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

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

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

If our system already contains separate mailing and home addresses for a subscriber, 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.

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

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.

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

There are a few potential causes:

  • Verify that you are 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. In such cases, please send the subscriber's application to your Membership Representative for manual entry.
  • If both of the above have been ruled out, please contact the InTouch for Administrators 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.

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

Please contact the InTouch for Administrators 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.

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

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

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

Other Coverage information and Prior Coverage information does not 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 Administrators Team after processing the online enrollment.

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

Please contact our InTouch for Administrators 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 Members

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 https:\\intouch.pacificsource.com\itm
  • 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.

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 at (888) 977-9299 or by e-mail and ask us to reset your password.

Why am I prompted to change my password? I use the site frequently.

All InTouch users are required to change their passwords every 90 days to maintain security standards and to comply with current HIPAA regulations.

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 and leave out any punctuation or special characters.

Are the answers to hint questions case-sensitive?

No, they are not case-sensitive.

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

Contact our Customer Service staff. You can reach us by phone at (888) 977-9299 during business hours, or by e-mail 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 valid e-mail address, so we can follow up promptly.

InTouch for Agents

Why am I having difficulty logging into InTouch for Agents?

You might be following an outdated link or bookmark to the login page. Try logging in by going directly to the Login page. You can also click on the InTouch Login link located on the upper right hand side of the screen on any page.

What do 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 and leave out any punctuation and special characters.

Are the answers to hint questions case-sensitive?

No, they are not case-sensitive.

Why am I prompted to change my password? I use the site frequently.

All InTouch users are required to change their passwords every 90 days to maintain security standards and to comply with current HIPAA regulations.

How can I set my computer to accept pop-up windows from PacificSource?

Choose your browser to view instructions on managing pop-ups:

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

You can reach the InTouch for Agents team by phone at (800) 624-6052 during business hours, or by e-mail at intouchforagents@pacificsource.com. Or, use the Contact Us form to get help with your question. 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 for Providers

Why am I having difficulty logging into InTouch for Providers?

You might be following an outdated link or bookmark to the login page. Try logging in by going directly to the Login page. You can also click on the InTouch Login link located on the upper right hand side of the screen on any page. 

What do 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 and leave out any punctuation and special characters.

Are the answers to hint questions case-sensitive?

No, they are not case-sensitive.

Why am I prompted to change my password? I use the site frequently.

All InTouch users are required to change their passwords every 90 days to maintain security standards and to comply with current HIPAA regulations.

Why won’t InTouch allow me to use my old password?

For security reasons, InTouch remembers your last three passwords and will not allow you to "recycle" them.

How can I set my computer to accept pop-up windows from PacificSource?

Choose your browser to view instructions on managing pop-ups:

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 at (888) 977-9299 or by e-mail and ask us to reset your password.

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

You are welcome to contact our Provider Network Department at (541) 684-5580 or toll-free at (800) 624-6052, ext. 2580. Or contact your Provider Service Representative directly. Please provide as many details as you can: your NPI, a detailed description of the problem you are encountering, any error message you are receiving, and screen shots if possible.

    Login To InTouch
Enter User Name:

Register Now

Last updated 11/19/2013