How to submit a complaint (aka: grievance) For all medical complaints, it’s recommended that you first contact UMP Customer Service. For prescription drug complaints or grievances, we recommend contacting WSRxS Customer Service. Many issues may be resolved with a phone call. If an initial phone call does not resolve your complaint, you may submit your complaint: • Over the phone: If you want a written response, you must request one. • By mail, fax, or email (see the “Where to send complaints or appeals” section below). You will receive notice of the action on your complaint or grievance within 30 calendar days of our receiving it. The plan will notify you if it needs more time to respond. What is an appeal? An appeal is an oral or written request submitted by you or your authorized representative to Regence BlueShield or WSRxS to reconsider: • A decision to deny, modify, reduce, or terminate payment, coverage, certification, or provision of health care services or benefits, including the admission to, or continued stay in, a health care facility. • A preauthorization. • A retroactive decision to deny coverage based on eligibility (see the “Appeals related to eligibility” section below). • Claims payment, processing, or reimbursement for health care services or supplies. The appeals process ALERT! If your appeal is for an urgent or life-threatening condition, see the "Expedited appeals process" section below. You or someone you authorize to represent you (see “How to designate an authorized representative” on page 139) may submit an appeal. There are three levels to the appeals process: 1. First-level appeal 2. Second-level appeal 3. External review (independent review) Each of those parts are described in further detail below. Coverage during each review If your request involves a decision to change, reduce, or terminate coverage for services, supplies, or prescription drugs already being covered, the plan must continue to cover the disputed service until the outcome of the review. If the plan upholds the decision to change, reduce, or terminate coverage, you will be responsible for the cost of the services received during the review period. If you request payment for denied claims or approval of services, supplies, or prescription drugs not yet covered by the plan, the plan will not cover the services, supplies, or prescription drugs while the appeal is under consideration. 128 2024 UMP Select (PEBB) Certificate of Coverage