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 • Medical records from your provider, if applicable. Your provider should supply clinically relevant information, such as medical records for services denied based on medical necessity or for other clinical reasons. The plan must receive all relevant information with the appeal to make sure the most accurate decision is made. First-level appeals You or your authorized representative may submit a first-level appeal no more than 180 days after you receive the plan’s decision. If you do not submit an appeal within this time, your appeal will not be reviewed, and you will not be able to continue further appeals (second-level and external review). 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). Regence BlueShield manages first-level appeals for medical services, and WSRxS manages first-level appeals for prescription drugs. Employees from Regence BlueShield and WSRxS reviewing the appeals will not have been involved in the initial decision you are appealing. Administrative staff review claim processing disputes. A staff of health care professionals at Regence BlueShield or WSRxS evaluate appeals that involve issues requiring medical judgment about covering, authorizing, or providing health care. ALERT! Deadlines for submitting an appeal are based on the first date you are notified of how a claim was processed, usually when you receive you an Explanation of Benefits (including services that applied to your deductible or were denied). The plan does not waive deadlines based on untimely billing by your provider. Second-level appeals If you disagree with the decision made on your first-level appeal, you or your authorized representative may submit a second-level appeal. You must submit second-level appeals no more than 180 days after you receive the letter responding to your first-level appeal. If you do not submit an appeal within this time, your appeal will not be reviewed, and you will not be able to continue further appeals (external review). You may authorize a representative to submit an appeal on your behalf in writing or by 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 127