What happens if you are not an appropriate candidate for spine care surgery under the COC Program If Virginia Mason Medical Center determines you are not an appropriate candidate for spine care surgery, you may still receive spine care surgery through other providers under this plan. Services received outside the COE Program are processed according to the plan’s medical policies, benefit structure, and the network status of your provider. Appeals related to the COE Program UMP members may appeal denials made by Premera. Appeals must be submitted to Premera. A decision by your Virginia Mason Medical Center provider regarding whether the provider is willing to perform spine care surgery on you is a decision of the provider, not the plan, and cannot be appealed to the plan or Premera. TIP: Appeal deadlines and other rules remain the same. See the “Complaint and appeal procedures” section for details of how non-COE appeals work. An appeal for services related to the COE Program must be submitted within 180 days after you receive notice of the denial to Premera, not to Regence or Virginia Mason Medical Center. Appeals can be submitted to: Premera Blue Cross Attn: Member Appeals PO Box 91102 Seattle, WA 98111-9202 Secure inbound fax: 1-425-918-5592 Substance use disorder See the “Behavioral health” benefit. Surgery Note: When you receive nonemergency services at a network hospital, network hospital outpatient department, network critical access hospital, or network ambulatory surgical center in Washington State, you pay the network rate and cannot be balance billed regardless of the network status of the provider. For nonemergency services performed at one of these facilities outside of Washington State, you still pay the network rate, but in some states, an out-of- network provider may be allowed to ask you to waive some of your balance billing protections. You pay the standard rate for covered surgical services. The plan pays for covered surgical services according to the network status of the provider. The surgeon and other professional providers may bill separately from the facility. Your provider must notify the plan when you are admitted for inpatient treatment and when you receive certain services. Some outpatient procedures require preauthorization. Find the list of services that require preauthorization on the UMP Policies that affect your care webpage. Contact UMP Customer Service if you have questions. See Directory for link and contact information. 2024 UMP CDHP (PEBB) Certificate of Coverage 73