For expedited appeals, the plan will decide as soon as possible but always within 72 hours. The plan will notify you (or your authorized representative) of the decision verbally within 72 hours and will mail a written notice within 72 hours of the decision. External review (independent review) You or your authorized representative may submit a request for an external review by an independent review organization (IRO) if you have gone through both a first- and second-level appeal (or expedited appeal) and your appeal was based on the plan’s decision to deny, modify, reduce, or terminate coverage of or payment for a health care service. You may also submit a request for an external review: • If the plan has exceeded the timelines for response to your appeal without good cause and without reaching a decision; or • If the plan has failed to adhere to the requirements of the appeals process. You may submit a request for an expedited external review if you meet the requirements for the expedited process as described above. You may also request an expedited external review at the same time that you request an expedited appeal, called concurrent expedited review. When you request concurrent expedited review, you are not required to go through both a first- and second-level appeal. An IRO will conduct the external review. An IRO is a group of medical and benefit experts certified by the Washington State Office of the Insurance Commissioner and not related to the plan, Regence BlueShield, WSRxS, or HCA. An external review provides unbiased, independent clinical and benefit expertise to determine whether the plan’s decision is consistent with state law and the 2024 UMP CDHP (PEBB) Certificate of Coverage. Requesting an external review To request an external review, see the contact information listed in the “Where to send complaints or appeals” section below. You or your authorized representative must submit a request for an external review no more than 180 days after you receive the letter responding to your second-level appeal (or expedited appeal). Only the member or an authorized representative may submit a request for an external review. You may authorize a representative to submit a request for an external review on your behalf in writing or by contacting UMP Customer Service (medical appeals) or WSRxS Customer Service (prescription drug appeals). The plan — Regence BlueShield for medical services, and WSRxS for prescription drugs — will send the IRO all of the relevant information and correspondence they considered in making the decision. You may send more information directly to the IRO. The IRO will notify you of their decision. Additional legal options You are required to exhaust the plan’s appeals process before you may bring a cause of action in court against the plan or HCA. If an IRO reviews your appeal, their decision is binding on both the plan and you except to the extent that other remedies are available under state or federal law. If the IRO overturns the plan’s decision the plan will provide benefits (including making payment on the claim) according to the IRO’s decision without delay, regardless of whether the plan intends to seek judicial review of the IRO’s decision and unless and until there is a judicial decision otherwise. Complaints about quality of care For complaints or concerns about the quality of care you received from preferred and participating providers only, contact UMP Customer Service or send a secure email through your Regence account. See Directory for link and contact information. 2024 UMP CDHP (PEBB) Certificate of Coverage 129