Substance use disorder See the “Behavioral health” benefit. Surgery Note: When you receive nonemergency services at a network hospital, network hospital outpatient department, network critical access hospital, or network ambulatory surgical center in Washington State, you pay the network rate and cannot be balance billed regardless of the network status of the provider. For nonemergency services performed at one of these facilities outside of Washington State, you still pay the network rate, but in some states, an out-of- network provider may be allowed to ask you to waive some of your balance billing protections. You pay the standard rate for covered surgical services. The plan pays for covered surgical services according to the network status of the provider. The surgeon and other professional providers may bill separately from the facility. Your provider must notify the plan when you are admitted for inpatient treatment and when you receive certain services. Some outpatient procedures require preauthorization. Find the list of services that require preauthorization on the UMP Policies that affect your care webpage. Contact UMP Customer Service if you have questions. See Directory for link and contact information. If services are inpatient (see definition of “Inpatient stay”), you will also pay an inpatient copay for facility charges at a preferred facility. The plan covers the following services as outpatient: • Outpatient surgery at a hospital • Short-stay obstetric (childbirth) services (released within 24 hours of admission) • Surgery and procedures performed at an ambulatory surgery center ALERT! All surgeries must follow the plan’s coverage rules. We recommend that you contact UMP Customer Service before any procedure to ask if it is covered or requires preauthorization. Temporomandibular joint (TMJ) disorder treatment The plan covers diagnosis and medically necessary treatment of temporomandibular joint (TMJ) disorders, including surgery and non-surgical services. Treatment must follow the plan’s medical policy and requires preauthorization. Treatment that is experimental or investigational, or primarily for cosmetic purposes, is not covered. Therapy: Habilitative and Rehabilitative Note: The total limit for therapies for inpatient habilitative and inpatient rehabilitative services is a combined limit of 60 days annually. The total limit for therapies for outpatient habilitative and outpatient rehabilitative services is a combined limit of 60 visits annually. 72 2024 UMP Select (PEBB) Certificate of Coverage