Documents

• InTouch for Providers Resource Guide (Revised July 2015)
  
• Provider Manual (Revised September 2018)
  

  The Provider Manual is your desktop reference for information about PacificSource Medicare policies and procedures. Updates are announced in the Provider Bulletin e-newsletter and on the Provider Newletters page of this Web site.

  If you have any questions or suggestions regarding this manual, you are welcome to contact your PacificSource Provider Service Representative at (800) 624-6052 ext. 2580 or email providerservicerep@pacificsource.com.

• Referral Frequently Asked Questions
  
• High Risk Medication Safer Alternatives
  

Forms

• Care Coordination and Case Management Referral Form
  
• Contested Refund Form
  
• Corrected Claim Form
  
• CVS Caremark Mail Order Prescription Fax Form for Prescribers
  
• EFT/ERA Election Form
  
• Health Services Prior Authorization Request Form
  
• EFT/ERA Election Form
  
• Hospice Pharmacy Prior Authorization Verification Form
  
• Inpatient Utilization Review Form
  
• Medicare Non-Coverage for Home Health
  
• Medicare Non-Coverage for Skilled Nursing Facilities
  
• Medicare Non-Coverage Instructions
  
• Pharmacy Prior Authorization Form
  
• Provider Appeal Form
  
• Referral Request Form
  
• Waiver of Liability for Non-Contracted Provider Claim Appeals