Get Pscs Provider Appeal Form - Pacificsource Community Solutions
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the PSCS Provider Appeal Form - PacificSource Community Solutions online
The PSCS Provider Appeal Form is a crucial document for providers seeking to appeal decisions made by PacificSource Community Solutions. This guide provides a clear and supportive approach to completing the form online, ensuring that all necessary information is included for a successful appeal.
Follow the steps to fill out the PSCS Provider Appeal Form online
- Press the ‘Get Form’ button to access the form and open it in your preferred online document editor.
- Begin by filling in the necessary identification fields at the top of the form. Provide the provider name and NPI number, ensuring accurate details are entered.
- Next, complete the contact information section. Include the contact name and phone number to facilitate communication regarding the appeal.
- In the member information section, enter the member's name and ID number, ensuring this matches PacificSource records.
- Provide the prior authorization number and claim number related to the appeal, along with the date of service (DOS) for context.
- Detail the item or service or prescription being appealed, along with any applicable CPT or HCPCS codes that correspond to the appeal.
- In the reasons for appeal section, clearly articulate the rationale for the appeal. Include any additional information that may be necessary for a thorough review. Ensure completeness to avoid the appeal being returned for more information.
- Attach any relevant documentation that supports your appeal request. Keep the documents organized without stapling them together; instead, use paperclips.
- Before completing the process, review all filled sections to verify accuracy and completeness. Finally, save your changes, and choose to download, print, or share the form as needed.
Complete your Provider Appeal Form online today for a streamlined submission process.
800-431-4135, TTY: 711 Please don't email personal information.
Fill PSCS Provider Appeal Form - PacificSource Community Solutions
Send this form to: PacificSource Community Solutions Provider Appeals. 2965 NE Conners Ave, Bend OR 97701 or via fax to . Please describe your appeal request and attach all relevant information and documentation that supports your request. Effective Date and Duration. This Contract Effective Date is October 1, 2019, regardless of the date of signature. If any changes occur with respect to Applicant's status regarding conflict of interest, Applicant shall promptly notify OHA in writing. 10. Use only one Provider Claim Appeal Form per request. 4. Send only one fax per reconsideration request. 5. For questions, please call CareSource Provider Claims at 1-, available Monday through Friday, 8 a.m. Submit a separate form for each claim appeal or reconsideration (i.e.
Industry-leading security and compliance
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.