First-level appeals You or your authorized representative may submit a first-level appeal no more than 180 days after you receive the plan’s decision. If you do not submit an appeal within this time, your appeal will not be reviewed, and you will not be able to continue further appeals (second-level and external review). You may authorize a representative to submit an appeal on your behalf in writing or by contacting UMP Customer Service (medical appeals) or WSRxS Customer Service (prescription drug appeals). Regence BlueShield manages first-level appeals for medical services, and WSRxS manages first-level appeals for prescription drugs. Employees from Regence BlueShield and WSRxS reviewing the appeals will not have been involved in the initial decision you are appealing. Administrative staff review claim processing disputes. A staff of health care professionals at Regence BlueShield or WSRxS evaluate appeals that involve issues requiring medical judgment about covering, authorizing, or providing health care. ALERT! Deadlines for submitting an appeal are based on the first date you are notified of how a claim was processed, usually when you receive you an Explanation of Benefits (including services that applied to your deductible or were denied). The plan does not waive deadlines based on untimely billing by your provider. Second-level appeals If you disagree with the decision made on your first-level appeal, you or your authorized representative may submit a second-level appeal. You must submit second-level appeals no more than 180 days after you receive the letter responding to your first-level appeal. If you do not submit an appeal within this time, your appeal will not be reviewed, and you will not be able to continue further appeals (external review). You may authorize a representative to submit an appeal on your behalf in writing or by contacting UMP Customer Service (medical appeals) or WSRxS Customer Service (prescription drug appeals). Regence BlueShield manages second-level appeals for medical services, and WSRxS manages second- level appeals for prescription drugs. Employees from Regence BlueShield and WSRxS reviewing the appeals will not have been involved in, or subordinate to anyone involved in, reviewing the first-level appeal or initial decision. If new or additional evidence or rationale is considered in reviewing your appeal, the plan will provide you with this information free of charge, and you may respond before the final decision. Expedited appeals process Expedited appeals for medical services You or your authorized representative may submit an expedited appeal within 180 days of receiving the previous decision if: • You are currently receiving or prescribed treatment or benefits that would end because of the denial; or • Your provider determines that taking the usual time allowed could seriously affect your life, health, or ability to regain maximum function, or would subject you to severe pain that cannot be adequately managed without the disputed care or treatment; or • The issue is related to admission, availability of care, continued stay, or emergency health care services and you have not been discharged from the emergency room or transport service. You may authorize a representative to submit an expedited appeal on your behalf in writing or by contacting UMP Customer Service. 130 2024 UMP Select (PEBB) Certificate of Coverage