Get the free pacificsource corrected claim form

Review your Explanation of Payment EOP to see if the second processing is included. Return the Corrected Claim Form to PacificSource Health Plans Claims Department Research Analyst PO Box 7068 Springfield OR 97475-0068 Fax 541 225-3634 Questions If you have any questions about corrected claims please feel free to contact your Provider Network Department at 541 684-5580 or toll-free at 800 624-6052 ext 2580 or by e-mail at ProviderServiceRep pacif...

How to fill out pacificsource corrected claim form

How to fill out pacificsource corrected claim form:

1. Review the form and ensure you have all the necessary information and documentation.
2. Begin by filling out the patient's personal information, including their name, address, phone number, and date of birth.
3. Provide the patient's insurance information, such as their policy number and group number.
4. Indicate the date of service for which the corrected claim is being submitted.
5. In the "Reason for Correction" section, clearly explain why the claim needs to be corrected. Be concise and specific.
6. Attach any supporting documentation, such as medical records or additional explanation, to justify the correction.
7. Double-check all the information provided to ensure accuracy and completeness.
8. Once the form is complete, submit it according to the instructions provided by Pacificsource.

Who needs pacificsource corrected claim form:

1. Individuals or healthcare providers who have submitted an incorrect or incomplete insurance claim to Pacificsource.
2. Anyone who has received a request from Pacificsource to correct a previously filed claim.
3. Healthcare providers who need to make adjustments or updates to their billing information for a specific patient's claim.

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What is pacificsource corrected claim form?

The pacificsource corrected claim form is a form that allows providers to submit corrected claims to PacificSource.

Who is required to file pacificsource corrected claim form?

Providers who need to correct a previously submitted claim to PacificSource are required to file the pacificsource corrected claim form.

How to fill out pacificsource corrected claim form?

To fill out the pacificsource corrected claim form, providers must enter the necessary information such as patient details, claim details, and the correction that needs to be made.

What is the purpose of pacificsource corrected claim form?

The purpose of the pacificsource corrected claim form is to allow providers to submit corrected claims and ensure accurate and timely processing.

What information must be reported on pacificsource corrected claim form?

The pacificsource corrected claim form requires providers to report the necessary information such as patient demographics, claim dates, original claim information, and the correction being made.