PRV1_0119_ProviderManual-Commercial.pdf

Physicians and providers will cooperate with

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• Physicians and providers will cooperate with PacificSource, to the extent permitted by law, in maintaining medical information with the express written consent of the insured, and in providing medical information requested by PacificSource when necessary to coordinate benefits, quality assurance, utilization review, third party claims, pre-existing condition investigations, and benefit administrations. PacificSource agrees that such records shall remain confidential unless such records may be legally released or disclosed. Unless otherwise specified, medical records shall be provided at no-cost. • For noncovered services, physicians and providers will look to the member for payment. • Provider shall look solely to PacificSource for compensation for Covered Services. Provider, or other designee or agent of Provider, shall not attempt to collect from Members any sums owed to Provider by PacificSource, notwithstanding the fact that either party fails to comply with the terms of this Agreement. Provider further agrees that if PacificSource determines that a Covered Service was not Medically Necessary, or that Covered Services are provided outside of generally accepted treatment protocols, Provider shall not attempt to collect from Member or PacificSource any sums deemed not reimbursable by PacificSource. • If PacificSource determines that a Covered Service was not Medically Necessary, or that Covered Services are provided outside of generally accepted treatment protocols, Provider shall not attempt to collect from Member or PacificSource any sums deemed not reimbursable by PacificSource, unless the member agreed in writing prior to service(s) being rendered that they were fully aware that said service(s) would be considered not medically necessary and that the member would be responsible for payment. • Additional agreement assumptions for contracted providers/entities which may be listed in your specific contract or will default and refer to the provider manual: • Practitioners may communicate freely with members/patients about their treatment plans, regardless of the benefit coverage or limitations to covered services. • Practitioners/Facilities allow the plan to use practitioner performance data. • Practitioners/Facilities cooperate with Quality Improvement Activities. • Practitioners/Facilities maintain the confidentiality of member information and records. For specific contract provisions, please refer to your direct contract or to the negotiating entity that contracted on your behalf. You are also welcome to contact our Provider Network department by phone at (541) 684-5580 or (800) 624-6052, ext. 2580, or by email at [email protected]
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Section 4 | Physicians and Providers 18 4.4.1 Medical Records and Chart Notes Requirements The purpose of practitioner signatures is to indicate that the services have been accurately and fully documented, reviewed and authenticated. The individual who ordered and/or provided services must be clearly
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  • Winter '16
  • Dr. Vincent Onyebuchi
  • PacificSource

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