If the plan asks you for more information, you will be allowed at least 45 days to provide it. If the plan does not receive the information requested within the time allowed, the plan will deny the claim. Complaint and appeal procedures ALERT! In the following section, UMP refers to the administrative functions for appeals for UMP Plus. Regence BlueShield handles medical appeals and WSRxS handles appeals involving prescription drugs. VSP handles appeals for routine vision benefits. See “Your routine vision benefits” for more information. Appeals procedures may change during the year if required by federal or Washington State law. What is a complaint (aka: grievance)? A complaint is an oral statement or written document submitted by or on behalf of a member regarding: • Dissatisfaction with medical care. • Dissatisfaction with service provided by the health plan. • Provider or staff attitude or demeanor. • Waiting time for medical services. Note: If your issue is regarding a denial, reduction, or termination of payment or nonprovision of medical services, it is an appeal. How to submit a complaint (aka: grievance) For all medical complaints, it’s recommended that you first contact UMP Customer Service. For prescription drug complaints or grievances, we recommend contacting WSRxS Customer Service. Many issues may be resolved with a phone call. If an initial phone call does not resolve your complaint, you may submit your complaint: • Over the phone: If you want a written response, you must request one. • By mail, fax, or email (see the “Where to send complaints or appeals” section below). You will receive notice of the action on your complaint or grievance within 30 calendar days of our receiving it. The plan will notify you if it needs more time to respond. What is an appeal? An appeal is an oral or written request submitted by you or your authorized representative to Regence BlueShield or WSRxS to reconsider: • A decision to deny, modify, reduce, or terminate payment, coverage, certification, or provision of health care services or benefits, including the admission to, or continued stay in, a health care facility. • A preauthorization. • A retroactive decision to deny coverage based on eligibility (see the “Appeals related to eligibility” section below). 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 125