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Over the next several months, we will be moving the content of this database to the UMP website. This change will allow you to access all UMP benefits information in one place. As content is moved, we will link to the information's new location.

  • 1. How do I submit an appeal or complaint regarding medical services or prescription drugs?
    For all complaints or grievances, begin by calling one of the phone numbers below. Many issues can be resolved this way. However, you do not have to call before sending in a written appeal or complaint. For issues involving prescription drugs Washington State Rx Services 1-888-361-1611 For issues involving medical services Uniform Medical Plan 1-888-849-3681 If you are not satisfied with the outcome of your phone call, send your written complaint or appeal by mail, fax, or email: ALERT! If you a  More...
  • 2. How can I appeal decisions about eligibility for coverage under UMP?
    %%pebb_elig%% Appeals related to eligibility and enrollment are handled by the Public Employees Benefits Board (PEBB) Program and governed by Washington Administrative Code (WAC) chapter 182-16 . Information on how to file an appeal is available: On the PEBB Appeals webpage . By contacting the PEBB Appeals Manager at 1-800-351-6827 or by email at pebappeals@hca.wa.gov
  • 3. What is an expedited appeal?
    Expedited Appeals for Medical Service Claims Involving Urgent Care If the plan denies coverage for services and your provider determines that taking the usual time allowed could seriously affect your life, health, or ability to regain maximum function, or would subject you to severe pain that cannot be adequately managed without the care or treatment, ask your provider to request an expedited appeal. An expedited appeal replaces the first- and second-level appeals. Regence BlueShield will decide  More...
  • 4. If I disagree with what UMP covers, what should I do?
    The Public Employees Benefits Board (PEBB) is responsible for designing benefits for UMP. If you would like to contact PEBB about what is covered, or to learn more about the process, see Who decides what UMP covers? How can I get involved in the process? . If you disagree with decisions relating to the processing of your claim, the availability of a health care service or coverage, authorization or provision of health care services, or benefits you feel have been wrongly denied, reduced, modifie  More...
  • 5. How does the independent review process work?
    External Review: Independent Review What Is An Independent Review Organization? An Independent Review Organization (IRO) will conduct the external review (also called an “independent review”). An IRO is a group of medical and benefit experts certified by the Washington State Department of Health and not related to the plan, Regence BlueShield, Washington State Rx Services, or the Health Care Authority. An IRO is intended to provide unbiased, independent clinical and benefit expertise  More...
  • 6. How long does the plan have to decide my appeal?
    Time Limits for the Plan to Decide Appeals The time limits below apply to both first- and second-level appeals, and are calculated from when the plan receives the appeal. The plan will decide on your appeal within 14 days of receipt but may take up to 30 days unless a different time limit applies as explained below. We will request written permission from you or your authorized representative when we need an extension to the 30-day timeline, to get medical records or a second opinion. The time l  More...
  • 7. What can I do if UMP denies my pharmacy claim?
    Call Washington State Rx Services at 1-888-361-1611 to find out why the claim was denied. If you disagree with the reason for the denial, you may request an appeal. For more information, read about our UMP Complaint and Appeal Procedures .
  • 8. How to Designate an Authorized Representative
    TIP: Because of privacy laws, the plan usually cannot share information on appeals or complaints with family members or other persons unless the patient is a minor, or the plan has received written authorization to release personal health information to the other person. To authorize someone to receive your protected health information, request an Authorization to Disclose Protected Health Information form (see below). This form must be returned to the address on the form before the plan can sha  More...
  • 9. If my doctor says I need to take a Tier 3 (nonpreferred) drug, can I get the Tier 3 drug at a lower tier cost? (UMP Classic and UMP Plus)
    %%umpplus_pres_drug%% You may request an exception to the Tier 3 cost-share. For Tier 3 drugs that have a generic equivalent, talk to your prescribing provider about whether an equivalent preferred drug is right for you. To check on alternatives to Tier 3 drugs on your plan's online Preferred Drug List , see the column Less Expensive Alternative. You always have the right to appeal any plan policy.
  • 10. When You Don’t Have Access to a Preferred Provider: Network Waiver (UMP Classic and UMP CDHP)
    ALERT! When requesting a network waiver after services are processed, you must submit your request within 180 days of receiving notice of payment (your Explanation of Benefits ) for the related services. See “After Services Are Provided” below for details. What Is a Network Waiver? An approved network waiver allows the plan to pay for services provided by an out-of-network provider at the network rate. You may request a network waiver only when you do not have access to a preferred p  More...

The certificate of coverage (COC) for the member's plan is the source of coverage provisions offered under the plans. If information given here is inconsistent with the applicable COC, the rules in the applicable COC will apply. Also, the COC may have additional information on this subject.

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