However we will accept submitted claims for a period

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within 90 days of service. However, we will accept submitted claims for a period of one year from the date of service. Additionally, PacificSource will accept rebillings six months from the date the original claim was processed. Initial bills, rebills, and adjustments that are received after this stated period of time will not be payable by PacificSource or by our member. PacificSource strives to make the claims process as efficient as possible. We ask that when you submit a corrected claim that it is submitted with our Corrected Claim Form and chart notes, if applicable. This form will help us to more easily assess the reason for the change, resulting in a faster turnaround time. Please do not submit corrected claims without the Corrected Claim Form as these are seen as duplicate submissions and will be denied. At this time we are unable to accept corrected claims in electronic format. You can find the Corrected Claim Form in the Providers > Forms and Materials section of our website, If a claim is not approved, and you believe it is an error, simply resubmit the claims and an explanation to PacificSource for reconsideration, providing time limitations are not exceeded. PacificSource will review the case to determine whether the claim is eligible for payment under the terms of the contract. You will be notified in writing of the determination. Note: Multiple resubmissions will calculate from the original date the claim was processed.
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Section 10 | Filing Claims 50 10.2.1 CMS 1500 Form Implementation In preparation for ICD-10, the CMS 1500 claim form has been updated to accommodate the new code set. Please be aware of the following time line: January 1–March 31, 2014: You can use either the current (08/05) or the revised (02/12) 1500 claim form. Health plans, clearinghouses, and billing vendors will accept and process either version of the form. Beginning April 1, 2014: The current (08/05) 1500 claim form will be discontinued; only the revised (02/12) 1500 claim form is to be used. All rebilling of claims will be on the revised (02/12) 1500 claim form from this date forward, even though earlier submissions may have been on the current (08/05) 1500 claim form. 10.3 UB04 Instructions The UB04 claim form is available in the For Providers– Forms section of our website, You may also obtain the form by contacting our Provider Network department by phone (541) 684-5580, or toll-free at (800) 624-6052, ext. 2580, or by email at [email protected] The preparation of the form in its entirety is encouraged. This will eliminate the need for PacificSource to request additional information, and will enable us to process the bill quickly. A separate billing form is required for each patient and must be legible. General and specific instructions are listed for assistance in completing the claim form correctly.
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  • Winter '16
  • Dr. Vincent Onyebuchi
  • PacificSource

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