When and how to request a network waiver Before your visit When services require preauthorization, you may request a network waiver before services are provided. Visit the UMP Policies that affect your care webpage for the list of services requiring preauthorization (see Directory for link). Your network waiver request should be included with the preauthorization request. See the “Information needed to submit a network waiver request” section below to learn what to include in your request. When the plan approves the network waiver before you receive medical services from an out-of-network provider: • You pay your cost-share for medical services the plan has approved through this waiver as though the provider is preferred. • You pay $0 for covered preventive services, including covered immunizations. The plan pays 100 percent of the allowed amount. After your visit When you receive any service, except those that require preauthorization, you may request a network waiver after the claims have been processed. Network waiver requests not approved in advance are considered an appeal and must be submitted within 180 days of receiving an Explanation of Benefits. See the “Complaint and appeal procedures” section for information about your appeal rights. Information needed to submit a network waiver request You should include all the following information in your request: • A letter of explanation from you or your provider stating the need to see the out-of-network provider. • Details of the research conducted by you or your provider to locate a preferred provider (e.g., dates network status was checked, names and phone numbers of preferred providers that were researched and may have been contacted before receiving services from the out-of-network provider). More information needed for preauthorization requests When submitting a request for preauthorization that includes a network waiver, all the following additional information should also be included: • Performing provider’s name, address, phone • Procedure codes number, and National Provider Identifier (NPI) • Length of treatment requested or required for or Tax ID number (TIN) services • Diagnosis codes • Estimated charges See the “Preauthorizing medical services” section for more information about requesting medical services preauthorization from the plan. Where to send your network waiver request UMP Member Appeals Regence BlueShield PO Box 1106 Lewiston, ID 83501-1106 If you have questions about the network waiver process, contact UMP Customer Service. 2024 UMP Select (PEBB) Certificate of Coverage 19