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  • 1. How do I submit an appeal or complaint regarding medical services or prescription drugs?
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    The following provides a brief overview of how you can appeal or complain to the plan. You can start with calling one of the phone numbers below. Many issues can be resolved this way. Customer Service for issues involving prescription drugs Washington State Rx Services 1-888-361-1611 Customer Service for issues not involving prescription drugs (medical services) Uniform Medical Plan 1-888-849-3681 If you are not satisfied with the outcome of your phone call (you do not have to call before sendin  More...
  • 2. How can I appeal issues relating to eligibility for coverage under UMP? (UMP Classic, UMP CDHP, and UMP Plus)
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    %%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 website . By contacting the PEBB Appeals Manager at 1-800-351-6827 or by email at pebappeals@hca.wa.gov
  • 3. Forms available online: Claim forms (medical and prescription drug), mail-order drug form, release forms, coordination of benefits (other coverage), some eligibility forms.
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    NOTE: Due to requirements regarding secure transmission of confidential information, we cannot post forms that may be filled and submitted online. However, you may print and complete the forms below and send via mail. Some may be filled in onscreen, then printed and mailed. Looking for phone numbers? Medical Forms Medical Claim form (236K) (for out-of-network provider services) See instructions for when and how to submit a medical claim Vision Claim Form (268K) (including eyeglasses and contacts  More...
  • 4. What is an expedited appeal?
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    Expedited Appeals for Medical Service Claims Involving Urgent Care There are two parts to the expedited appeal process: first-level appeal and independent review. 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.   More...
  • 5. How does the independent review process work?
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    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 preauthorization for medical services works
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    TIP: It is important to ensure that all needed information is sent to the plan. Sending insufficient information may lead to delays, or denial of services. See the list of services that require preauthorization. Your provider must submit a preauthorization request. The documentation needed depends on the service for which preauthorization is being requested. Providers may access plan medical policies online , or call Provider Services at 1-888-849-3682. Your provider will be notified that: The s  More...
  • 7. How long does the plan have to decide my appeal?
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    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. When your   More...
  • 8. If I disagree with what UMP covers, what should I do?
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    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, modifi  More...
  • 9. How to Designate an Authorized Representative
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    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...
  • 10. Prescription Drug Contact Information
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    Washington State Rx Services 1-888-361-1611 7:30 am to 5:30 pm, Monday through Friday Network Mail-Order Pharmacy Faxing prescriptions to PPS (Postal Prescription Services) Note: Only a provider can fax a prescription. 1-800-552-6694 Fax 1-800-723-9023 (providers only) Mailing a prescription order Postal Prescription Services PO Box 2718 Portland, OR 97208-2718 Contact PPS for how to place a mail order Specialty pharmacy (Ardon Health) (see Specialty drugs under UMP ) 1-855-425-4085 Fax 1-855  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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