• UMP (Regence) Medical Claim Form — You may find the form by visiting forms and publications at hca.wa.gov/ump-forms-pubs or you may request a form by contacting UMP Customer Service. • An itemized bill from your provider that describes the services you received and the charges. The following information must appear on the provider’s itemized bill for the plan to consider the claim for payment: • Member’s name and member ID number, including the alpha prefix (three letters and the ‘W’ before member ID number) • Procedure and diagnosis code(s) or description of the injury or illness • Date and type of service • Provider’s name, address, phone number, and National Provider Identifier (NPI) or Tax ID number • For ambulance claims, also include the ZIP code of where the member was picked up and where they were taken If UMP is secondary, you must include a copy of your primary plan’s Explanation of Benefits, which lists the services covered and how much the other plan paid. You should wait until the primary plan has paid to submit a secondary claim to UMP, unless the primary plan’s processing of the claim is delayed. Claims not submitted to UMP within 12 months of the date of service will not be paid. If we must request additional information, the processing of your claim may be delayed. Note: Be sure to make copies of your documents for your records. Mail both the claim form and the provider’s claim document (or bill) to: Regence BlueShield Attn: UMP Claims PO Box 1106 Lewiston, ID 83501-1106 Or you can fax documents to Regence at 1-877-357-3418. The plan may send reimbursement for services received from an out-of-network provider to the provider or to you in the form of a check listing both you and the provider as payees. If you paid up front for services, proof of payment may be required. Contact UMP Customer Service if you have a question about the processing of your claim or for information on what is acceptable as proof of payment. Important information about submitting claims ALERT! You or your provider must submit claims within 12 months of the date you received health care services. This is called the “timely submitting” deadline. The plan will not pay claims submitted more than 12 months after the date of service. See “Submit secondary claims promptly” on page 123 for how this works when you have other coverage that pays first. For information about submitting claims for services outside of the U.S., contact UMP Customer Service. You may have to pay services upfront and submit a claim for reimbursement. If you have other health care coverage, see the “If you have other medical coverage” section for information on how the plan coordinates benefits with other plans. Services apply to your UMP medical deductible in the order claims are received, not necessarily in the order the member receives services. 2024 UMP Select (PEBB) Certificate of Coverage 125