Appeals related to eligibility Appeals related to eligibility and enrollment are handled by the PEBB Program and governed by chapter 182-16 WAC. Information on how to file an appeal is available: • On the HCA website at hca.wa.gov/pebb-appeals. • By contacting the PEBB Appeals Unit at 1-800-351-6827 (TRS: 711). Where to send complaints or appeals ALERT! Premera handles appeals for the COE Program. See the “Joint replacement surgery, knees and hips in the Centers of Excellence (COE) Program” and “Spine care in the Centers of Excellence (COE) Program” benefits for more information. VSP handles appeals for routine vision benefits. See “Your routine vision benefits” for more information. It is recommended that you call first with a complaint or appeal, since many problems may be resolved quickly over the phone. The Directory at the beginning of this booklet includes links and contact information to contact UMP (medical services) or WSRxS (prescription drugs) with a complaint or appeal. When another party is responsible for injury or illness You may receive a letter from the plan asking if your injury or illness was the result of an accident or might be someone else’s responsibility. To make sure claims are paid in a timely manner, it is important that you respond as directed in the letter, even if the answer is no. If you do not, the plan may deny coverage. You may contact UMP Customer Service if you have questions. Occupational injury or illness (workers’ compensation) claims When a claim for occupational injury or illness (workers’ compensation) is accepted by your employer’s workers' compensation carrier, UMP will not cover any services related to that injury or illness, even if the compensation carrier denies some services. You must file a workers’ compensation claim with your workers’ compensation carrier. If your claim for workers’ compensation is denied because it is determined the injury or condition is not related to an occupational injury or illness, UMP will pay for covered services under the terms of this COC. Legal rights and responsibilities Coverage under the plan is not provided for medical, dental, prescription, or vision expenses you incur for treatment of an injury or illness if the costs associated with the injury or illness may be covered by another first party insurance or may be recoverable from any of the following: • A third party; • Any other source, including no fault automobile medical payments (Med-Pay), no fault automobile personal injury protection (PIP), homeowner’s no-fault coverage, commercial premises no-fault medical coverage, and sports policies. This includes excess, underinsured, or uninsured motorist coverage, or 2024 UMP Select (PEBB) Certificate of Coverage 133