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Appeals Guide

We hope this guide provides you with the answers you are seeking about the appeals process. Please contact the Grievance & Appeals Department at 541-330-4992 with any questions.


Provider Appeals

All appeals must be received by the plan within 60 calendar days of the coverage determination date (i.e. Explanation of Payment, Denial of Medical Coverage). The plan may consider exceptions to the filing timelines within reasonable limits if you can show ‘good cause’ that prevented timely filing due to circumstances beyond your control. Please provide this information with your appeal.

Untimely appeals without 'good cause' will be dismissed without review.

Upon receipt, we will send you a notice to acknowledge your appeal. This provides direct contact information should you have any questions or wish to provide additional information during the review process.

Authorization Appeals

If the appeal involves utilization management issues, please note that we will only reconsider a non-coverage decision if you provide additional information, not previously reviewed by the plan, that you believe will impact our original decision. Submit your request using the PacificSource Medicare Provider Appeal Form. Please fill it out completely. The form includes mailing and fax information.

Your appeal should include supporting medical information indicating why the original decision should be overturned. Appeals based on a denial of coverage as experimental/investigational should also include peer-reviewed literature supporting your position. Appeals that indicate disagreement with a coverage decision, without providing information to support further review, may result in an unchanged decision.

Every effort is made by appeal representatives to process your requests and issue a resolution as quickly as possible. This may take up to 30 calendar days. A review may be expedited if a physician requests it, with clear indication that potentially waiting up to 30 calendar days to receive a coverage decision may place the patient’s health in jeopardy. I.e., the plan will not rush the review of a MRI coverage appeal because the procedure is scheduled to occur prior to the 30-day timeframe. When the plan accepts a request to expedite a review, a coverage resolution will be issued within 72 hours of receipt or your request.

When a pre-approval has been denied because the plan reviewer requested additional documentation but did not receive it in a timely manner, resulting in a denial of coverage, please consider submitting a new pre-approval request with the additional information instead of an appeal. Clearly indicate new information is being provided.

This is the only level of appeal available to providers who are not the member’s treating physician. Authorization appeals that are submitted by a member’s treating physician on behalf of the member, whether contracted or not contracted with the plan, will follow an automatic second level review process if the non-coverage decision is upheld. If you are a treating physician filing on behalf of the member, CMS requires that you provide notice to the member that you are appealing the non-coverage decision.

Prescription Coverage Appeals

If the appeal involves a Part D prescription issue, please submit your request using the PacificSource Medicare Provider Appeal Form. If you are the prescriber, you have a choice as to whether to use the Provider Appeal Form, or the member's Request for Redetermination of Medicare Prescription Drug Denial Form. Please fill these out completely. The forms include mailing and fax information.

Your appeal should include supporting medical information indicating why the original decision should be overturned. Appeals that indicate disagreement with a coverage decision, without providing additional information to support further review, may result in an unchanged decision.

Every effort is made by appeal representatives to process your requests as quickly as possible. This may take up to 7 calendar days. We will consider expediting a decision if a physician requests it, with clear indication that potentially waiting up to 7 calendar days to receive a coverage determination may place the patient’s health in jeopardy. When the plan accepts a request to expedite a review, a coverage resolution will be issued within 72 hours of receipt or your request.

If the plan does not change its decision to deny coverage of a Part D prescription during the appeals process, you will receive further appeal rights with the determination letter, should you or the member choose to exercise them.

Claim Appeals

If your appeal involves claim non-payment ($0 payment) issues, please include clear documentation that will help us research the claim in question. You can include a copy of the original claim, the Explanation of Payment, and any records that support your argument for payment. Submit your request using the PacificSource Medicare Provider Appeal Form. Please fill it out completely. The form includes mailing and fax information.

Claims denied for reasons such as invalid coding, invalid place of service, duplicate claim, timely filing, etc, should not be submitted via the appeals process. In these cases, it is more appropriate to contact the Claims Department with your reconsideration request. The plan makes every effort to publish and make available our pre-approval requirements via the Authorization Grid. However, typical claim appeals involve denials based on lack of pre-approval. These are some examples of appeals that may result in upheld denials.

  • Provider used an incorrect authorization grid, or indicates unawareness of pre-approval requirements.
  • Provider did not confirm member’s coverage prior to provision of services, and was unaware of, or did not follow pre-approval requirements.
  • Provider’s records indicate accurate coverage information. However, staff did not contact plan to obtain a pre-approval.
  • Provider failed to call with utilization review and notification of an inpatient admission.
  • The treating provider indicates the referring provider did not obtain a pre-approval. The plan considers that it is the responsibility of both providers to confirm pre-approval.

This is the only level of appeal available to contracted providers.

Non-contracted providers: per The Centers for Medicare and Medicaid Services (CMS), we may only accept a non-payment claim appeal if you provide a signed Waiver of Liability with your request. In signing the Waiver of Liability, you agree to not bill the member regardless of the appeal resolution. Appeals that do not provide a Waiver of Liability within 60 calendar days of receipt will be dismissed by the plan without review. If you provide a Waiver of Liability and the non-coverage decision is upheld, your appeal will follow an automatic second level review process.

If you are a non-contracted provider and your issue involves a dispute regarding the amount of reimbursement made by the plan for a covered service, where you believe the plan paid a lower amount than Original Medicare would allow, please refer to the Non-Contracted Providers Claims Payment Dispute Process section below.

Appeal Resolutions

Reviewers who were not involved in the initial coverage decision participate in the appeal review. A resolution will be issued to you (the appellant) in writing within 30 calendar days of receipt of the appeal for a standard review, 7 calendar days for a Part D prescription review, and 72 hours for an expedited review. These timeframes may be extended if the reviewer requires additional information to make a determination, or the provider or member requests it.

All appeal resolutions are subject to plan benefits, medical necessity, coverage criteria, and member’s enrollment status at the time of service.


Non-Contracted Providers Claims Payment Dispute Process

The Center for Medicare and Medicaid Services (CMS) has provided an avenue by which non-contracted providers may dispute the amount of reimbursement made by the plan for a covered service. These include any decisions where a non-contracted provider contends that the amount paid by PacificSource Medicare for a covered service is less than the amount that would have been paid under Original Medicare. Provider payment disputes also include instances where there is a disagreement between a non-contracted provider and the plan about the plan’s decision to pay for a different service than that billed, often referred to as down-coding of claims.

This process is not available to plan contracted providers.

The plan will accept payment disputes from a non-contracted provider when they are filed in writing within 120 calendar days from the date of the notice of the organization determination (Explanation of Payment). Please submit your written request with all of these required elements:

  • Provider contact information, including name and address;
  • Pricing information, including NPI number (and CCN / OSCAR number for institutional providers), zip code where services were rendered, and physician specialty;
  • An attestation that the provider is a non-contracted provider;
  • The reason for the dispute and a description of the specific issue;
  • Copy of your claim as submitted to the plan for payment, with the disputed portion identified;
  • Copy of the plan’s original pricing determination (Explanation of Payment);
  • Any documentation or correspondence that supports your position that the plan's reimbursement is not correct (this may include interim rate letters, where appropriate);
  • Appointment of Provider Representative Authorization Statement, if applicable; and
  • The name and signature of the provider or the provider's representative.

Your requests can be mailed to:

PacificSource Medicare
Attn: Non-Contracted Provider Appeals
2965 NE Conners Ave
Bend, Oregon 97701

Alternatively, you can fax your dispute to:

541-322-6424

Untimely payment disputes will not be considered by the plan, unless you provide a ‘good cause’ justification such as a natural disaster, which prevented a timely submission.

If you have questions about submitting your written payment dispute, please call PacificSource Medicare at 888-863-3637. Our hours of operation are:

From October 1 to February 14: 8:00 a.m. to 8:00 p.m. local time zone, seven days a week.
From February 15 to September 30: 8:00 a.m. to 8:00 p.m. local time zone, Monday through Friday.

We will acknowledge receipt of your dispute and issue you a written resolution within 30 calendar days of receipt.


Member Appeals

Plan members have additional appeal rights as provided by The Center for Medicare and Medicaid Services and Coding of Federal Regulations, and are distinct from provider appeals. These rights are issued in their Member Handbook (Evidence of Coverage), Denial of Medical Coverage/Denial of Payment notices, and Explanation of Benefits.

A physician may also support a member’s request for an expedited (72-hour) appeal by calling the Grievance & Appeals Department at 541-330-4992 or in writing via fax at 541-322-6424. We will resolve a member’s expedited appeal within 72 hours of receipt, if it includes physician’s support indicating that potentially waiting up to 30 calendar days (for medical services) or 7 calendar days (for Part D prescriptions) for a decision may place the member’s health or life in jeopardy.