[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-239065-105":53,"doc-detail-239065-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","how-to-submit-an-insurance-claim-to-pacificsource-step-by-step-instructions","How to Submit an Insurance Claim to PacificSource - Step-by-Step Instructions","","Step-by-step guidance for submitting an insurance claim to PacificSource using the HealthInformation Portal. Instructions cover locating and printing the Walkout/statement after selecting the visit date, verifying and recording the PacificSource Member ID, and adding required identifiers such as name and Member ID on the statement. The process then explains optional use of the PacificSource Claim Form, preparing for mailing, using a business reply envelope (no postage necessary), or emailing the claim with the required personal information.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/how-to-submit-an-insurance-claim-to-pacificsource-step-by-step-instructions/239065/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/how-to-submit-an-insurance-claim-to-pacificsource-step-by-step-instructions/239065.png","ImageObject",442,249,{"name":88,"@type":89},"Jasmine","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-11",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Where can the visit statement needed for a claim be found and printed?","Question",{"text":109,"@type":110},"Locate and print the visit statement from the HealthInformation Portal. Sign in, open Statements, then select the visit date to download or print the Walkout Statement.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How do you find your PacificSource Member ID?",{"text":114,"@type":110},"Use the digital ID card page at the provided PacificSource URL. On the first page, enter your name and DOB, choose an identification method from the drop-down, and proceed to generate the PDF with your member number.",{"name":116,"@type":107,"acceptedAnswer":117},"What are the mailing or email options for submitting the claim?",{"text":118,"@type":110},"Mail the statement using the pre-addressed business reply envelope available at the Student Health Center (no postage necessary). Alternatively, email the claim to CS@Pacificsource.com and include your name and Member ID number.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},239065,1791122384,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},2336478487870,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","# How to Submit an Insurance Claim to PacificSource\n\nLocate and print the statement from your office visit on the HealthInformation Portal.  \n1.Go to https://lclark.medicatconnect.com/and sign in.If you need help with logging in,please see the second page of the document at  \nhttps://www.Iclark.edu/live/files/36330-health-information-portal-guide.  \n2.Click on“Statements”on the left side navigation bar.  \n3.Click on the date of the visit for which you want to submit a claim.  \nHealth Center statements  \nPast Statements View and Download  \nWednesday.March 27.2024Monday,November 6.2023Monday,November 6.2023Monday,October 9.2023  \n4.When you click on the statement date,a new tab will appear with a Walkout Statementthat you can download or print.  \n5.Print the Walkout Statement using the printer icon at the top right of the screen.  \nWalkout Statement  \nTidle Sumea:  \n67445  \nLewis麦Clark Colege Student Health Center  \nFodenil ID:  \nWalker Kathleen,NP  \n1275199048  \nNPI  \n615S Palatine Hill Rd.  \n615S.Palatine Hill Rd  \nPortland,OR 97219-8091  \nPorland,OR 97219  \nPhene:  (503)768-7165  \nFax:  \n(503)768-7167  \nAccount  \n                Aoou Nunker!         \nTestpatient,Mom  \nBlahblah,OR 97000  \n0L/10/1990  \nCampusAdrese  \nDiagmesk                    \n\n| Dak   | CPTCde   | Derpi   | Im  \u003Cbr>NDC   | Chure   | Psmc   |\n| --- | --- | --- | --- | --- | --- |\n| 037272024   | 99214   | RE:Suden Hcalth Office Visit 30 Mins.   | 1   | 50.00   | 50.00   |\n| 037272024   | 99213   | RE:Sudent Hcalth Office Visit 15 Mins,   | 1   | S0.00   | S0.00   |\n|  |  |  | Total:   | 50.00   | 50.00   |\n|  |  |  | Today's Balance:   |  | S0.00   |\n|  |  |  | Previos Balanc;   |  | S89800   |\n|  |  |  | Account Balance:   |  | 5898.00   |\n|  | This fee has been charged to your student account.Please forward to your  \u003Cbr>insurance company for reimbursement.   |  |  |  |  |\n|  |  |  |  |  |  |\n\nLocate your member ID number  \n6.Locate your PacificSource Member ID.If you don't know your member ID number,go tohttps://intouch.pacificsource.com/Members/ldCard/Printable to get a digital ID card (PDF).On the first page enter your name,DOB,and then in the drop-down menu under \"IdentifyUsing\"choose another method of identification(e.g.Social Security Number or Student IDnumber),Enter that information and click next.A PDF of a member ID card will populatethat has your member number and other information.  \n\n| ---------------------------------  \u003Cbr>②PacificSource  \u003Cbr>HEALTH PLANS  \u003Cbr>MEMBER ID:_-  \u003Cbr>GROUP ID:G0035861  \u003Cbr>SUBSCRIBER:Your Name  \u003Cbr>ID MEMBER EFFECTIVE cOVERAGE  \u003Cbr>00 First Name 8/15/2024 M D V   | --------  \u003Cbr>GROUP:  \u003Cbr>Lewis &Clark College  \u003Cbr>NETWORK:  \u003Cbr>Navigator  \u003Cbr>NAT'L NETWORK:  \u003Cbr>Aetna Signature  \u003Cbr>Administrators PPO  \u003Cbr>OR  \u003Cbr>DRUG LIST  \u003Cbr>004336  \u003Cbr>RXBIN  \u003Cbr>RXGROUP RX6155  \u003Cbr>ADV  \u003Cbr>RXPCN  \u003Cbr>PAYORID 93029   | DEDUCTIBLE  \u003Cbr>Ou-of-Net.  \u003Cbr>In-Net.  \u003Cbr>Out-of-Net.In-Net.  \u003Cbr>Medical,  \u003Cbr>$500  \u003Cbr>S10,500  \u003Cbr>$3,500  \u003Cbr>S900  \u003Cbr>Rx,and  \u003Cbr>Vision  \u003Cbr>MEDICAL BENEFITS &ELIGIBILITYINFORMATION:  \u003Cbr>Members:855-274-9814|StudentHealth@PacificSource.com  \u003Cbr>aetna  \u003Cbr>Providers:855-896-5208|StudentHealth@PacificSource.com  \u003Cbr>Aualatle outsided  \u003Cbr>DENTAL:866-373-7053|Dental@Pacificsource.com  \u003Cbr>ID.OR MT,andWA  \u003Cbr>PHARMACISTS:844-877-4803|Fax541-225-3665  \u003Cbr>Aetna Suyature  \u003Cbr>AdminstabrsPPO  \u003Cbr>nmoeco-trot  \u003Cbr>Verify benefits on InTouch at PacificSource.com/StudentHealth  \u003Cbr>PaciicSource Health Plans |PO Box7068,Springfeld,OR 97475-0068  \u003Cbr>This card is not an authorization for services or a guarante of payment.   |\n| --- | --- | --- |\n\n\n| OUT OF POCKET MAX   |\n| --- |\n\nIf you would like,you can complete and print the Claim Form-Medical found at  \n7.Write your full name and PacificSource Member ID on the statement.  \nYour Name(First and Last)  \nPacificsource Member ID\\#[member number from member ID card]  \n\n| Lewis &Clark College Student Health Center  \u003Cbr>615 S Palatine Hill Rd.  \u003Cbr>Porland,OR 97219","cbCait7ETsZLnRzI","https://ap.wps.com/l/cbCait7ETsZLnRzI","pdf",1200346,"English","# How to Submit an Insurance Claim to PacificSource\n## Prepare the Statement for Mailing\n## After submitting your claim","[{\"question\":\"Where can the visit statement needed for a claim be found and printed?\",\"answer\":\"Locate and print the visit statement from the HealthInformation Portal. Sign in, open Statements, then select the visit date to download or print the Walkout Statement.\"},{\"question\":\"How do you find your PacificSource Member ID?\",\"answer\":\"Use the digital ID card page at the provided PacificSource URL. On the first page, enter your name and DOB, choose an identification method from the drop-down, and proceed to generate the PDF with your member number.\"},{\"question\":\"What are the mailing or email options for submitting the claim?\",\"answer\":\"Mail the statement using the pre-addressed business reply envelope available at the Student Health Center (no postage necessary). Alternatively, email the claim to CS@Pacificsource.com and include your name and Member ID number.\"}]","How to Submit an Insurance Claim to PacificSource - Step-by-Step Instructions | PDF",1789143052]