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. If services are inpatient (see definition of “Inpatient stay”), you will also pay an inpatient copay for facility charges at a network facility. The plan covers the following services as outpatient: • Outpatient surgery at a hospital • Short-stay obstetric (childbirth) services (released within 24 hours of admission) • Surgery and procedures performed at an ambulatory surgery center ALERT! All surgeries must follow the plan’s coverage rules. We recommend that you contact UMP Customer Service before any procedure to ask if it is covered or requires preauthorization. Temporomandibular joint (TMJ) disorder treatment The plan covers diagnosis and medically necessary treatment of temporomandibular joint (TMJ) disorders, including surgery and non-surgical services. Treatment must follow the plan’s medical policy and requires preauthorization. Treatment that is experimental or investigational, or primarily for cosmetic purposes, is not covered. Therapy: Habilitative and Rehabilitative Support network provider type: You must use a UMP Plus–UW Medicine ACN provider or a covered provider within the support network to receive network level benefits (see description in the “Support network providers” section). Note: The total limit for therapies for inpatient habilitative and inpatient rehabilitative services is a combined limit of 60 days annually. The total limit for therapies for outpatient habilitative and outpatient rehabilitative services is a combined limit of 60 visits annually. Habilitative (Neurodevelopmental) Services The plan covers inpatient and outpatient habilitative (neurodevelopmental) services to assist a person to keep, learn, or improve skills and functioning for daily living. This could be related to issues such as: • A congenital anomaly (such as cleft lip or palate). • Conditions of developmental delay, including autism. For the purposes of this benefit, developmental delay means a significant lag in achieving skills such as: • Cognitive (thinking). • Language (speech, reading, writing). • Motor (crawling, walking, feeding oneself). • Social (getting along with others). 72 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage