INSURER FILING GUIDE

PacificSource Health Plans

Use this public information to prepare your packet, then confirm the route on the insurer's own page.

AT A GLANCE

Claim facts

Member form	Claim Form - Medical Number: CLB814 Revision: 2024-04 (printed in month/year order) Open the insurer form
Portal upload	NO
Portal path	NO: the current claim page and claim form publish only nonportal submission routes
Mail address	PacificSource Health Plans, PO Box 7068, Springfield, OR 97475-0068
Fax	541-225-3632
Attachments	Patient name; date of service; procedure codes; ICD diagnosis codes; healthcare professional full name, credentials, address, phone, TIN, and NPI if assigned; total charge for each service; employer name and group number when applicable; accident details when applicable
Deadline	PacificSource encourages submission within 90 days and accepts claims for 1 year after service
Outcome and status	InTouch > Look up a claim; Customer Service; an EOB is issued after processing
Processing time	Not published by the insurer
Caveats	Out-of-network benefits are plan-specific. The same public claim route covers medical services, including outpatient behavioral health. Medicare and Medicaid are outside this read.

STEP BY STEP

Read date: 10-09-2026

Complete Claim Form - Medical CLB814. Include the member, patient, provider, service, diagnosis, procedure, and charge fields printed on the form. https://pacificsource.com/sites/default/files/2022-02/CLB814_0222_ClaimForm-Medical.pdf
Add a copy of the original itemized provider receipt and proof of payment. The itemized bill must carry every provider, patient, date, code, credential, identifier, and charge field published on the current claim page. https://pacificsource.com/members/learn-about-my-plan
Sign the Authorization/Certification. PacificSource requests a completed claim form plus supporting documents, so a superbill alone is not sufficient. https://pacificsource.com/sites/default/files/2022-02/CLB814_0222_ClaimForm-Medical.pdf
NO PORTAL UPLOAD: the current claim page and form publish only nonportal submission routes. PacificSource encourages submission within 90 days and accepts a claim for one year after service. https://pacificsource.com/members/learn-about-my-plan
PacificSource issues an explanation of benefits after processing. Use InTouch > Look up a claim or Customer Service to check status. NOT PUBLISHED: claim processing time and electronic submission confirmation. https://pacificsource.com/members/learn-about-my-plan

Portal upload: NO
Portal: PacificSource public claim instructions
Portal path: NO: the current claim page and claim form publish only nonportal submission routes
Mail address: PacificSource Health Plans, PO Box 7068, Springfield, OR 97475-0068
Fax: 541-225-3632
Attach: patient name; date of service; procedure codes; ICD diagnosis codes; healthcare professional full name, credentials, address, phone, TIN, and NPI if assigned; total charge for each service; employer name and group number when applicable; accident details when applicable
File types: NOT PUBLISHED
File size limit: NOT PUBLISHED
Maximum files: NOT PUBLISHED
One file or separate files: Completed claim form, copy of the original itemized provider receipt, and proof of payment
Confirmation: NOT PUBLISHED
Status check: InTouch > Look up a claim; Customer Service; an EOB is issued after processing
Processing time: NOT PUBLISHED
Member deadline: PacificSource encourages submission within 90 days and accepts claims for 1 year after service
Deadline basis: Member handbook or policy controls; rebillings have a separate published limit
Mental health route: PacificSource behavioral health

Confirm the address, fax number or portal path on the insurer's own claims page before you send; read on 10-09-2026.

Read on 10-09-2026 from https://pacificsource.com/sites/default/files/2022-02/CLB814_0222_ClaimForm-Medical.pdf. Confirm the address, fax number or portal path on the insurer's own claims page before you send.