Mail both the claim form and the provider’s claim document (or bill) to: Regence BlueShield Attn: UMP Claims PO Box 1106 Lewiston, ID 83501-1106 Or you can fax documents to Regence at 1-877-357-3418. The plan may send reimbursement for services received from an out-of-network provider to the provider or to you in the form of a check listing both you and the provider as payees. If you paid up front for services, proof of payment may be required. Contact UMP Customer Service if you have a question about the processing of your claim or for information on what is acceptable as proof of payment. Important information about submitting claims ALERT! You or your provider must submit claims within 12 months of the date you received health care services. This is called the “timely submitting” deadline. The plan will not pay claims submitted more than 12 months after the date of service. See “Submit secondary claims promptly” on page 121 for how this works when you have other coverage that pays first. For information about submitting claims for services outside of the U.S., contact UMP Customer Service. You may have to pay services upfront and submit a claim for reimbursement. If you have other health care coverage, see the “If you have other medical coverage” section for information on how the plan coordinates benefits with other plans. Services apply to your UMP medical deductible in the order claims are received, not necessarily in the order the member receives services. Claims reimbursement Most of the time, the plan will pay network providers directly. For claims submitted by you or an out-of- network provider, the plan will determine whether to pay you, the provider, or both. For a child covered by a legal qualified medical child support order (see page 118) the plan may pay the child’s custodial parent or legal guardian. Claims determinations The plan will notify you of action taken on a claim within 30 days of the plan receiving it. This 30-day period may be extended by 15 days when action cannot be taken on the claim due to: • Circumstances beyond the plan’s control. Notice will include an explanation why an extension is needed and when the plan expects to act on the claim. • Lack of information. The plan will notify you within the 30-day period that an extension is necessary, with a description of the information needed and why it is needed. Submitting a claim for prescription drugs You may need to submit your own prescription drug claim to WSRxS for reimbursement if you: • Buy prescription drugs at a non-network retail pharmacy. • Fail to show your UMP member ID card at a network pharmacy. • Have other prescription coverage that pays first, and UMP is secondary. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 123