“Notice” means that your provider must contact the plan to let us know when you receive services. Notice is usually done by the facility when you are admitted. ALERT! If the plan denies preauthorization and you receive those services anyway, you are responsible for the provider’s entire billed charge. How long the plan has to make a decision The plan will respond to standard preauthorization requests submitted by contracted providers within 5 days of receipt for non-electronic requests and within 3 days of receipt for electronic requests. For expedited preauthorization requests, the plan will respond within 1 to 2 days of receipt. If additional information is required, the plan will notify the provider within the timelines described in this section. You will also be notified of the decision. If your provider believes that waiting for a decision under the standard preauthorization timeframe could place your life, health, or ability to regain maximum function in serious danger, they can request an expedited preauthorization request. General information from UMP Customer Service For services not requiring preauthorization, you may contact UMP Customer Service to ask if a particular service is generally covered by the plan, and for an estimate of how much you will pay. The plan does not approve or deny preauthorization for services that are not on the UMP preauthorization list. Until a claim is submitted and reviewed, the plan cannot guarantee that your service will be covered or give you an exact amount you will pay out of pocket. This is because when a provider bills for a service, the plan pays for it based on procedure codes. Each code describes a service in some detail, and there are many codes for similar-sounding services. Your provider, not the plan, determines which of these codes is used on the submitted claim. Alternative benefits Alternative benefits mean benefits for services or supplies that are not otherwise covered as specified in this COC, but for which the plan may approve coverage after case management evaluation. The plan may cover alternative benefits through case management (see the “Care management” benefit) if the plan determines that alternative benefits are medically necessary and will result in overall reduced covered costs and improved quality of care. Before alternative benefits are covered, the plan, you (or your legal representative), and, if required by the plan, your physician or other provider, must enter into a written agreement of the terms and conditions for payment. Alternative benefits are approved on a case-specific basis only. Approval of an alternative benefit applies to only the services and member listed in the written agreement. The rest of this COC remains in effect. What the plan does not cover TIP: If you have any questions about services the plan does not cover, contact UMP Customer Service or WSRxS Customer Service. 106 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage