Coverage during each review If your request involves a decision to change, reduce, or terminate coverage for services, supplies, or prescription drugs already being covered, the plan must continue to cover the disputed service until the outcome of the review. If the plan upholds the decision to change, reduce, or terminate coverage, you will be responsible for the cost of the services received during the review period. If you request payment for denied claims or approval of services, supplies, or prescription drugs not yet covered by the plan, the plan will not cover the services, supplies, or prescription drugs while the appeal is under consideration. First-level and second-level appeal reviewers Claim processing disputes will be reviewed by administrative staff. The plan will consult with a health care professional employed by Regence BlueShield on medical appeals, or with a health care professional employed by Washington State Rx Services on prescription drug appeals, when appeals involve issues requiring medical judgment about covering, authorizing, or providing health care. That includes decisions based on determinations that a treatment, prescription drug, or other item is experimental, investigational, or not medically necessary. Your appeal will be reviewed by Regence BlueShield or Washington State Rx Services employees who have not been involved in, or subordinate to anyone involved in, reviewing the previous decisions. How to submit an appeal You or your authorized representative (including a relative, friend, advocate, attorney, or provider) may submit an appeal by using the methods described below in the “Where to send complaints or appeals” section. You may authorize a representative to submit an appeal on your behalf in writing or by contacting UMP Customer Service (medical appeals) or WSRxS Customer Service (prescription drug appeals). For each appeal request, you must appeal within 180 days of receiving the plan’s decision. You may include written comments, documents, and any other information, such as medical records and letters from your provider, to support your appeal request. The plan will consider all information submitted when reviewing your appeal. You may also request copies of documents the plan has that are relevant to your appeal, which the plan will provide at no cost to you. The plan will mail you a written response within 14 days of receiving your appeal request. If more time is needed to thoroughly research and review your appeal, the plan is allowed up to 30 days to respond. The plan will ask your permission if it needs more time to respond. You can access the UMP (Regence) Medical appeals and grievance form by visiting forms and publications at hca.wa.gov/ump-forms-pubs. Information to provide with an appeal You can submit information, documents, written comments, records, evidence, and testimony, including second opinions, with your appeal. When you provide all the necessary documentation, it allows the plan to review your appeal faster. Include the following when requesting an appeal: • The member’s full name (the name of the employee, retiree, or dependent covered by the plan) • The member ID number (starting with a “W” on your UMP member ID card) • The name(s) of any providers involved in the issue you are appealing • Date(s) of service or incident • Your mailing address • Your daytime phone number(s) • A statement describing the issue and your desired outcome • A copy of the Explanation of Benefits, if applicable, or a list of the claim numbers you are appealing 126 2024 UMP CDHP (PEBB) Certificate of Coverage