covered. Notice is usually done by the facility at the time you are admitted. Notice is not the same as preauthorization and many services require both. What is the difference between preauthorization and notice? ALERT! Many services, including, but not limited to, inpatient services, require both preauthorization and notice. Contact UMP Customer Service or talk to your provider if you have questions about services needing preauthorization or notice. “Preauthorization” is when your provider sends a request for coverage of a service on the UMP preauthorization list. Preauthorization is usually requested by the provider performing the services. The plan sends either an approval or denial of coverage. If the plan does not approve services that require preauthorization before services are received, the plan may deny coverage. The plan does not approve or deny preauthorization for services that are not on the UMP preauthorization list. “Notice” means that your provider must contact the plan to let us know when you receive services. Notice is usually done by the facility when you are admitted. ALERT! If the plan denies preauthorization and you receive those services anyway, you are responsible for the provider’s entire billed charge. How long the plan has to make a decision The plan will respond to standard preauthorization requests submitted by contracted providers, within 5 days of receipt for non-electronic requests and within 3 days of receipt for electronic requests. For expedited preauthorization requests, the plan will respond within 1 to 2 days of receipt. If additional information is required, the plan will notify the provider within the timelines described in this section. You will also be notified of the decision. If your provider believes that waiting for a decision under the standard preauthorization timeline could place your life, health, or ability to regain maximum function in serious danger, they can request an expedited preauthorization request. General information from UMP Customer Service For services not requiring preauthorization, you may contact UMP Customer Service to ask if a particular service is generally covered by the plan, and for an estimate of how much you will pay. The plan does not approve or deny preauthorization for services that are not on the UMP preauthorization list. Until a claim is submitted and reviewed, the plan cannot guarantee that your service will be covered or give you an exact amount you will pay out of pocket. This is because when a provider bills for a service, the plan pays for it based on procedure codes. Each code describes a service in some detail, and there are many codes for similar-sounding services. Your provider, not the plan, determines which of these codes is used on the submitted claim. Alternative benefits Alternative benefits mean benefits for services or supplies that are not otherwise covered as specified in this COC, but for which the plan may approve coverage after case management evaluation. The plan may 2024 UMP CDHP (PEBB) Certificate of Coverage 105