Claims - PEBB

Claims & appeals

When you use a network provider or network pharmacy, you don’t need to submit a claim—the provider or pharmacy will do it for you. But there are some circumstances where you will need to submit a claim. Claims must be submitted within 12 months of the date of service.

 Medical claims

You may need to submit a claim for payment if:

  • You receive services from an out-of-network provider. That provider may submit a claim on your behalf, so ask.
  • You have dual coverage (other insurance that pays first and UMP is secondary). If you’re a Medicare retiree, visit the Medicare page to learn how Medicare and UMP work together.
  • If you get a vaccine or flu shot from an out-of-network provider, you must submit the claim to Regence as a medical claim. Washington State Rx Services will deny out-of-network vaccine claims.

UMP does not cover nor coordinate benefits with worker's compensation claims. When a claim for workers’ compensation is accepted as being caused by a work-related injury or illness, all services related to that injury or illness are not covered, even if some services are denied by workers’ compensation. See “Does UMP coordinate with occupational injury or illness claims?” in your certificate of coverage.

For information on false claims, see “False claims or statements” in your certificate of coverage.

 How to submit a claim

You can submit a claim online through your Regence account, or you can fax or mail your claim to Regence. First, you'll need to gather these documents:

  1. The Medical Claim Form

  2. An itemized bill from your provider that describes the services and charges. The following information must be on the bill:

    a. Patient's name and plan ID number, including the three letters before the ID number

    b. Description of the injury or illness

    c. Date and type of service

    d. Provider's name, address and phone number

    e. For ambulance claims, include the ZIP code where the patient was picked up and where they were taken.

  3. If you have dual coverage and UMP pays second, you must include a copy of your primary plan's Explanation of Benefits for the service. You should wait until the primary plan has paid to submit a secondary claim to UMP, unless the claim processing is delayed. Claims not submitted to UMP within 12 months of the date of service will not be paid.

Mail the claim form and the provider's bill to:

Regence BlueShield
P.O. Box 1106
Lewiston, ID 83501-1106
Or fax it to 1 (877) 357-3418

If you have questions about submitting a claim for services outside the U.S., call UMP Customer Service.

Claims determinations You’ll be notified of action taken on a claim within 30 days of the plan receiving it. This may be extended by 15 days if more information is needed. If you’re asked for more information, you’ll be allowed at least 45 days to provide it.

Manage your claims See the status of your claims, see how much you owe, find a specific claim and more by logging in to your Regence account.

 Prescription drug claims

You must submit prescription drug claims within 12 months of purchase.

If you buy your prescription drugs at a network pharmacy, your claim will be submitted for you. You may need to submit your own claim if you buy drugs at a non-network pharmacy, don’t show your ID card, or have other prescription coverage that pays first and UMP is secondary.

To submit a claim, download the Prescription Drug Claim Form, fill it out and send it with your pharmacy receipts, to:

Washington State Rx Services
Attn: Pharmacy Claims
P.O. Box 40168
Portland, OR 97240-0168

Fax: 1 (800) 207-8235

Manage your claims Get your prescription claims history, view your benefits and claims information and more by logging in to your Washington State Rx Services account.

 Complaints

A complaint can be verbal or written and deals with dissatisfaction with medical care, waiting time for medical services, provider or staff attitude or demeanor, or dissatisfaction with service provided by UMP. See “Complaints about quality of care” in your certificate of coverage to learn more.

If your issue is regarding denial of payment or non-provision of medical services, it is an appeal.

How to file a complaint

Many issues can be resolved with a phone call. If an initial phone call doesn’t resolve your complaint, you may submit your complaint over the phone or by email, fax or mail. If you want a written response, you must request one.

Make sure you submit your complaint to the right company (see below). While it's a good idea to submit a complaint as soon as possible, there isn't a deadline to do so.

You’ll receive notice of the action on your complaint within 30 calendar days of our receiving it. We will notify you if we need more time to respond.

 Appeals

An appeal is a verbal or written request to reconsider a decision about:

  • Claims payment, processing or reimbursement for health care services, supplies, or prescription drugs
  • A decision to deny, change, reduce or end payment, coverage, certification or use of health care services, benefits, prescription drugs, or facilities
  • Coverage denial based on eligibility
  • A pre-authorization.

Appeals process

You, your provider, or a representative you authorize may request an appeal for you. There are three parts to the appeals process: first-level, second-level, and independent review. First- and second-level appeals are part of an internal review process, while independent reviews are part of an external review process. You may request an appeal no more than 180 days after you receive notice of a decision.

For more information about the appeals process, including expedited appeals for urgent or life-threatening conditions and requesting an external review by an Independent Review Organization, read the "Complaint and appeal procedures" section in your plan's certificate of coverage.

For more information about authorizing a representative to request an appeal for you, read the “Confidentiality of your health information” section of your plan’s certificate of coverage

How to file an appeal

You may send an appeal by telephone, mail, fax, or email. Make sure you contact the right company (see below). Please include the following information when requesting an appeal:

  • The subscriber’s full name (the name of the employee or retiree covered by the plan).
  • The patient’s full name (the name of the employee, retiree, or dependent covered by the plan).
  • The subscriber’s ID number (starting with a “W” on your ID card).
  • The name(s) of any providers involved in the issue you are appealing.
  • The dates when services were provided.
  • Your mailing address.
  • Your daytime phone number(s).
  • A statement of what the issue is and what you are asking for.
  • A copy of the Explanation of Benefits, if applicable.
  • Medical records from your provider, if applicable. For cases in which the denial of coverage is based on medical necessity or other clinical reasons, your provider should supply clinically relevant information, such as medical records or any other relevant information, along with your appeal.

The plan will send confirmation when it has received your appeal. For first- and second-level appeals, you will also receive notice of the action on your appeal within 30 calendar days. We will ask your permission if we need more time to respond. For expedited appeals, you will receive verbal notification within 72 hours.

Though it is not required, it may help to include the UMP Appeals and Grievance form (for medical services) or the Washington State Rx Services Complaint and Appeal Form (for prescription drugs) with your appeal. It explains what information should be included, and it lists the address and fax number.

 Where to send complaints and appeals

Choose the right company to process your complaints and appeals:

Medical services

UMP Customer Service

Online: Your Regence account
Phone: 1 (888) 849-3681
TRS: 711
Fax: 1 (877) 663-7526

Business hours: Monday through Friday 5 a.m. to 8 p.m. and Saturday 8 a.m. to 4:30 p.m. (Pacific)

Mail:
ASO Member Appeals
Regence BlueShield
PO Box 91015
Seattle, WA 98111-9115

Prescription drugs

Washington State Rx Services
Online: Your pharmacy account
Phone: 1 (888) 361-1611
TRS: 711
Fax: 1 (866) 923-0412

Business hours: 24 hours a day, 7 days a week

Mail:
Washington State Rx Services
Attn: Appeals
PO Box 40168
Portland, OR 97240-0168

Centers of Excellence Program

For knee and hip replacement and spine care

Premera
Online: Premera
Phone: 1 (855) 784-4563
TRS: 711
Fax: 1 (800) 995-2430

Business hours: 7 a.m. to 5 p.m. Monday through Friday (Pacific)

Mail:
Eligibility Appeals
Attn: Appeals Department - MS 123
PO Box 91102
Seattle, WA 98111-9102

Eligibility, enrollment, premiums

PEBB Program
Online: PEBB Program home page
Phone: 1 (800) 200-1004
TRS: 711

Business hours: Monday through Friday 8 a.m. to 4:30 p.m. (Pacific)

 If you have other coverage

“Coordination of benefits” happens when you have health coverage through two or more groups (such as your employer and your spouse’s employer), and these two health plans both pay a portion of your claims. If you or your dependents have other insurance, you must let Regence BlueShield and Washington State Rx Services know so claims are paid correctly:

Complete and mail or fax a Medical Multiple Coverage Inquiry Form to Regence:

Regence BlueShield
Attn: UMP Claims
PO Box 91015
MS BU 386
Seattle, WA 98111-9115

Fax: 1 (877) 357-3418

Complete and mail or fax a WSRxS Multiple Pharmacy Coverage Inquiry Form (Drug Coordination of Benefits) to Washington State Rx Services. You can also submit the form online through your pharmacy account.

Washington State Rx Services
PO Box 40168
Portland, OR 97240-0168

Fax: (800) 207-8235

You should also let your health care providers and your network pharmacy know if you have other coverage. If your coverage changes, call UMP Customer Service. All claims must be submitted to UMP within 12 months of the date of service or purchase to prevent denial of the claim.

If you or your dependents are enrolled in UMP CDHP and want to enroll in another health plan, you and your dependents can only enroll in other high-deductible health plans. The second high-deductible health plan cannot include an HSA. See the “About the UMP Consumer-Directed Health Plan” and “If you have other high-deductible health plan medical coverage” sections in the UMP CDHP certificate of coverage for more information on secondary health plans and limitations.

If you’re a Medicare retiree, visit the Medicare page to learn how Medicare and UMP work together.

How it works

If UMP pays first, or is your primary payer of your medical coverage, it pays the normal benefit amount. When UMP pays second to another plan, UMP will pay only the amount needed to bring the total benefit up to the amount it would have paid if you did not have another plan. When UMP pays second, you must still pay your deductible before UMP pays benefits.

For more information about dual coverage, read the “If you have other medical coverage” section in your plan’s certificate of coverage.

For prescription drug coverage, show both plan cards to the pharmacy and make sure they know which plan to bill first. If you use mail-order pharmacy and your primary plan uses Postal Prescription Services (PPS) as the network mail-order pharmacy, PPS can process payments for both plans and charge only what is left. Make sure PPS has the information for both plans and knows which plan is primary. If your primary plan uses a different mail-order pharmacy, you will have to use your primary plan’s mail order pharmacy, then submit a claim to Washington State Rx Services.

Some of the limits and restrictions to prescription drug coverage will apply when UMP pays second to another plan. Read the "Guidelines for drugs UMP covers" section of your certificate of coverage for details.

Diabetes care supplies

UMP covers glucose monitors through the medical benefit and other diabetes care supplies under the prescription drug benefit. How the claim is processed when UMP pays second may depend on where you get your supplies. See "How are diabetes care supplies covered when UMP pays second" in your plan's certificate of coverage for more information.

For Medicare retirees coverage may be different depending on whether Medicare pays the claim under the Part B medical benefit. Read "Diabetes care supplies when Medicare pays first" in your plan’s certificate of coverage for more information.

 Need help?

Call UMP Customer Service for help with any questions when you or a family member is covered by more than one plan.