The plan must preauthorize some medical services and supplies to determine whether the service or supply meets the plan’s medical necessity criteria to be covered. The fact that a service or supply is prescribed or furnished by a provider does not, by itself, make it a medically necessary covered service. Preauthorization is not a guarantee of coverage. A change after the plan has approved a preauthorization request — including, but not limited to, a change of provider or different/additional services — requires your provider to submit a new preauthorization request and for the plan to approve it. If your preauthorization is denied, your provider may request a peer-to-peer review where they can talk to a Regence BlueShield provider about your condition prior to submitting an appeal. For more information contact UMP customer service. Your preauthorization role ALERT! Excluded, experimental, and investigational services do not require preauthorization because they are not covered by the plan. To confirm whether a service is covered, contact UMP Customer Service. To be covered, some services, including, but not limited to, Applied Behavior Analysis (ABA) Therapy for members age 18 or older (see page 38) and bariatric surgery (see page 39), must be preauthorized before services are received. A preferred or participating provider may be required to request preauthorization before providing services. Contact UMP Customer Service to ask if a service requires preauthorization and how to submit a request. An out-of-network provider is not obligated to obtain preauthorization for services that require a preauthorization because they do not have a contract with Regence. If an out-of-network provider does not obtain a required preauthorization in advance of the service, you will be responsible for all charges billed to you. You are encouraged to request that an out-of-network provider preauthorize certain services on your behalf to determine medical necessity before the services are provided. They have the clinical details and technical billing information needed to submit a request. You may be liable for all charges if you receive services that are determined to be not medically necessary, experimental or investigational, or not covered under this plan (see the “What the plan does not cover” section). ALERT! See the “Complaint and appeal procedures” section for how to appeal denial of a preauthorization request before receiving services. List of services and supplies requiring preauthorization or notice For a list of services and supplies requiring preauthorization or notice: • Visit the UMP Policies that affect your care webpage. • Contact UMP Customer Service to request a printed list or ask questions. See the Directory pages at the beginning of this booklet for links and contact information. 2024 UMP Classic (PEBB) Certificate of Coverage 109