When your network provider affiliated with UMP Plus–UW Medicine ACN determines you need covered medically necessary services not available within your UMP Plus–UW Medicine ACN network, that provider submits a network consent request to the network for consideration by calling UMP Plus–UW Medicine ACN Customer Service at 1-888-402-4237 (TRS: 711) or contact UMP Customer Service. If they approve the network consent, the network will fax it to the plan before the services are provided. The fact that a provider may prescribe or provide a service or supply does not, by itself, make it a medically necessary covered service or supply. The network consent must include the following: • Information about the out-of-network provider and/or facility, such as name, address, and Tax ID number (TIN). • The dates of service for which your UMP Plus–UW Medicine ACN network provider is requesting network consent. When preauthorization is required with network consent The services you receive through network consent may also require UMP preauthorization. In that case, your network provider affiliated with UMP Plus–UW Medicine ACN must include information relevant to both the network consent and the UMP preauthorization request: • The information about the out-of-network provider and/or facility listed in the previous section; and • Clinical documentation needed for the plan to review services for medical necessity. For the plan to pay for out-of-network services at the network rate, the plan must approve a network consent before you receive services. A network consent is not guaranteed. Services received outside the service area UMP members have access to Regence BlueShield network providers and Blue Cross and Blue Shield Plan providers worldwide through the BlueCard® and Blue Cross Blue Shield Global® Core programs. Coverage available by region The table below shows the medical coverage available to you outside the UMP Plus service area in Washington State, in the rest of the U.S., and worldwide. Type of In Washington State In the U.S. (except Outside the U.S. service Washington State) Emergency You pay 15% of the You pay 15% of the You pay 15% of the room (ER) allowed amount* allowed amount* allowed amount See “Emergency room” benefit for details. Urgent care You pay 15% of the You pay 15% of the You pay 15% of the See “Urgent allowed amount for allowed amount for allowed amount for care” benefit network providers and 50% network providers and 50% network providers and 50% for details. of the allowed amount for of the allowed amount for of the allowed amount for out-of-network providers.* out-of-network providers.* out-of-network providers. 24 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage