|
Allowed amount is the most UMP pays for a specific covered service or supply. See the table below for how UMP determines the allowed amount for specific services and provider types.
Note: The UMP fee schedule identifies certain services and procedures that are reimbursed on a case-specific ("by report") basis. The allowed amount for those services or procedures may be based on UMP's fee schedule amounts for comparable services or procedures, Medicare's fee schedules, rates negotiated by case managers, or other method(s) at UMP's discretion.
UMP has the right to determine the amount payable for any service or supply.
| Type of Provider/Service |
Provider Network Status |
Location of Provider |
Allowed Amount |
| Professional services, durable medical equipment, supplies, and prostheses |
Network |
Throughout the U.S., including in Washington State |
Lesser of UMP contracted fee schedule amount or billed charge |
| Non-network |
Inside Washington State and the border counties of Idaho |
Lesser of the UMP fee schedule amount or billed charge |
| Non-network |
Outside Washington State and the border counties of Idano |
Lesser of billed charge or a regionally adjusted charge |
| Hospitals and other facilities |
Network |
Inside and outside Washington State |
As contracted with UMP |
| Non-network |
Inside Washington State |
Based on allowed amounts for network facilities |
| Non-network |
Outside Washington State |
Eligible billed charges, or rates negotiated with the facility |
| Prescription drugs* |
All prescription drug providers (network and non-network) |
Everywhere, including outside the U.S. |
Washington State Rx Services' standard reimbursement, unless other contractual arrangements or terms apply |
* When medications not normally self-administered are received in a provider's office, the UMP allowed amount is based on a percentage of the Average Wholesale Price (AWP) or a percentage of the Average Sales Price (ASP). The ASP is determined by the Centers for Medicare & Medicaid Services.
|
