• Dissatisfaction with medical care. • Dissatisfaction with service provided by the health plan. • Provider or staff attitude or demeanor. • Waiting time for medical services. Note: If your issue is regarding a denial, reduction, or termination of payment or nonprovision of medical services, it is an appeal. How to submit a complaint (aka: grievance) For all medical complaints, it’s recommended that you first contact UMP Customer Service. For prescription drug complaints or grievances, we recommend contacting WSRxS Customer Service. Many issues may be resolved with a phone call. If an initial phone call does not resolve your complaint, you may submit your complaint: • Over the phone: If you want a written response, you must request one. • By mail, fax, or email (see the “Where to send complaints or appeals” section below). You will receive notice of the action on your complaint or grievance within 30 calendar days of our receiving it. The plan will notify you if it needs more time to respond. What is an appeal? An appeal is an oral or written request submitted by you or your authorized representative to Regence BlueShield or WSRxS to reconsider: • A decision to deny, modify, reduce, or terminate payment, coverage, certification, or provision of health care services or benefits, including the admission to, or continued stay in, a health care facility. • A preauthorization. • A retroactive decision to deny coverage based on eligibility (see the “Appeals related to eligibility” section below). • Claims payment, processing, or reimbursement for health care services or supplies. The appeals process ALERT! If your appeal is for an urgent or life-threatening condition, see the "Expedited appeals process" section below. You or someone you authorize to represent you (see “How to designate an authorized representative” on page 136) may submit an appeal. There are three levels to the appeals process: 1. First-level appeal 2. Second-level appeal 3. External review (independent review) Each of those parts are described in further detail below. 2024 UMP CDHP (PEBB) Certificate of Coverage 125