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 to UMP for payment if:

  • You receive services from an out-of-network provider. Out-of-network providers may submit a claim on your behalf. Ask your provider.
  • You have 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 Classic interact when Medicare pays first, and UMP Classic pays second.
  • You get a vaccine or flu shot from an out-of-network provider. You must submit the claim to Regence as a medical claim.

UMP does not cover nor coordinate benefits with workers' compensation claims. When a claim for workers’ compensation is accepted, all services related to that injury or illness are not covered, even if some services are denied by workers’ compensation. See “Occupational injury or illness (workers' compensation) 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 appear on the provider's itemized bill for the plan to consider the claim for payment:

    a. Member's name and member ID number, including the alpha prefix (three letters and the "W" before member ID number)

    b. Procedure and diagnosis (codes) or description of the injury or illness

    c. Date and type of service

    d. Provider's name, address, phone number, and National Provider Identifier (NPI) or Tax ID number

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

  3. 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 UMP Claims
P.O. Box 1106
Lewiston, ID 83501-1106

Or you can fax documents to Regence at 1 (877) 357-3418.

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

Claims determinations The plan will notify you of action taken on a claim within 30 days of the plan receiving it. This 30-day period may be extended by 15 days when action cannot be taken on the claim due to:

  • Circumstances beyond the plan’s control. Notice will include explanation why an extension is needed and when the plan expects to act on the claim.
  • Lack of information. The plan will notify you within the 30-day period that an extension is necessary, with a description of the information needed and why it is needed.

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.

 Vision Service Plan (VSP) claims

When you visit a Vision Service Plan (VSP) Choice network provider, the doctor will submit the claim directly to VSP for payment.

If you are a member and are age 19 or over and you see an out-of-network provider, you pay 100 percent of the billed charges. You can submit the claim online or by mail.

When you submit a claim, attach an itemized receipt that includes the following information:

  • Doctor's name or office name
  • Name of patient
  • Date of service; and
  • Each service received and the amount paid.

To submit the out-of-network claim online, visit the VSP website and select "Start new claim."

To submit a claim by mail download and complete the VSP Request for Reimbursement form and mail it to the address below. If you have questions on how to fill out this claim form, contact VSP Member Services at 1-800-877-7195. Deaf, DeafBlind, Late Deafened and Hard of Hearing members call: 1-800-428-4833.

Vision Service Plan
Attention: Claims Services
P.O. Box 385018
Birmingham, AL 35238-5018

You have 12 months from the date of service to submit your claim. If you do not submit your claim within 12 months of the date of service, it will be denied. If you disagree with how your claim was processed, you may file a complaint or an appeal.

 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.

For prescription drugs filled in 2021, Complete the 2021 Prescription Drug Claim Form 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

For prescriptions filled in 2022, complete the 2022 Prescription Drug Claim Form and send it with your pharmacy receipts to: Pharmacy Manual Claims P.O. Box 999 Appleton, WI 54912-0999 Fax: 1 (855) 668-8550

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.

 Complaint or Grievance

A complaint or grievance 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 non-provision of medical services, it is an appeal.

See “Complaints about quality of care” in your certificate of coverage to learn more.

How to file a complaint

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 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 an oral or written request submitted by you or your authorized representative to Regence BlueShield or Washington State Rx Services 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 pre-authorization.
  • A retroactive decision to deny coverage based on eligibility. See “Appeals related to eligibility” section of your plan's certificate of coverage.
  • Claims payment, processing, or reimbursement for health care services or supplies.

Appeals process

You or someone you authorize to represent you may request an appeal. There are three levels to the appeals process: first-level, second-level, and external review (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 must submit first-level and second-level appeals no more than 180 days after receiving the previous 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 submit an appeal

You or your authorized representative (including a relative, friend, advocate, attorney, or provider) may submit an appeal by using the methods described in the “Where to send complaints or appeals” section below or by calling UMP Customer Service (medical appeals) or WSRxS Customer Service (prescription drug appeals). Make sure you contact the right company (see below). Please include the following information when requesting an appeal:

  • The member’s full name (the name of the employee, retiree, or dependent covered by the plan)
  • The member ID number (starting with a “W” onyour UMP member ID card)
  • The name(s) of any providers involved in the issue you are appealing
  • Date(s) of service or incident
  • Your mailing address
  • Your daytime phone number(s)
  • A statement describing the issue and your desired outcome
  • A copy of the Explanation of Benefits, if applicable, or a list of the claim numbers you are appealing
  • Medical records from your provider, if applicable. Your provider should supply clinically relevant information, such as medical records for services denied based on medical necessity or for other clinical reasons. The plan must receive all relevant information with the appeal to make sure the most accurate decision is made.

The plan will send confirmation when it receives your appeal. You will also receive a decision on your appeal within 30 calendar days. We will ask your permission if we need more time to respond. The plan will decide on your expedited appeal within 72 hours of the request. Your provider must submit all clinically relevant information to the plan by phone or fax.

Though it is not required, you may want 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. These forms explain what information should be included with your appeal and list the address and fax number of where to send your appeal.

 Where to send complaints and appeals

Choose the right company to process your complaints and appeals:

Medical services

To appeal online, sign in to your Regence account, select Programs & Resources, and select Appeals.

You can also download the appeal form and submit your written appeal by email, fax, or mail:
Email: UMPMemberAppeals@regence.com
Fax: 1 (877) 663-7526

Mail:
UMP Appeals and Grievances
Regence BlueShield
PO Box 91015
Seattle, WA 98111-9115

To appeal by phone or if you have questions, contact UMP Customer Service at 1 (888) 849-3681 (TRS: 711) Monday through Friday 5 a.m. to 8 p.m. and Saturday 8 a.m. to 4:30 p.m. (Pacific).

Vision services

Complaints or appeals can be submitted through written or verbal request as described below.

Online: Visit VSP’s Member Grievance page, and complete the online form.

Mail:
Vision Service Plan
Attention: Complaint and Grievance Unit
P.O. Box 997100
Sacramento, CA 95899-7100

To appeal by phone, or if you have questions, contact VSP Member Services at 1 (844) 299-3041 Monday through Friday 5 a.m. to 8 p.m.; Saturday 7 a.m. to 8 p.m.; Sunday 7 a.m. to 7 p.m. (Pacific). Deaf, DeafBlind, Late Deafened and Hard of Hearing members call 1 (800) 428-4833.

Prescription drugs

You can download the appeal form and submit your written appeal by fax or mail:

Fax: 1 (866) 923-0412

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

If you have questions, contact Washington State Rx Services Customer Service at 1 (888) 361-1611 (TRS: 711) Monday through Friday 7:30 a.m. to 5:30 p.m. (Pacific). They are also available outside these hours with limited services.

Centers of Excellence Program

For knee and hip replacement and spine care

An appeal for services related to the Centers of Excellence Program must be submitted within 180 days after you receive notice of the denial to Premera.
Submit appeals to:

Fax: 1 (800) 995-2430

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

If you have questions, contact Premera at 1 (855) 784-4563 (TRS: 711) Monday through Friday 7 a.m. to 5 p.m. (Pacific).

Eligibility, enrollment, premiums

Any enrollee may appeal a decision made by the Public Employees Benefits Board (PEBB) Program regarding PEBB eligibility, enrollment, premium payments, or premium surcharges (if applicable) to the PEBB Appeals Unit. Learn more on the HCA website.

For questions about appeals, call: 1 (800) 351-6827.

If you have questions about eligibility and enrollment:
Employees:
Contact your payroll or benefits office.
Retirees and PEBB Continuation Coverage members: Call the PEBB Program
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 medical or prescription coverage

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

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

Regence BlueShield
Attn: UMP Claims
PO Box 91015
MS BU386
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 call Washington State Rx Services with the information at 1 (888) 361-1611 (TRS: 711).

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

Fax: (800) 207-8235

If your coverage changes, call UMP Customer Service and Washington State Rx Services. 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 Consumer-Directed Health Plan (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 UMP Consumer-Directed Health Plan” and “If you have other HDHP 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

When the plan is the primary payer (pays first), UMP pays its normal benefit as described in the certificate of coverage. When UMP pays second to another plan that covers the member, UMP will pay only an amount needed to bring the total benefit up to the amount UMP would have paid if the member 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” (or for UMP CDHP "If you have other HDHP 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 the remaining unpaid balance. 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 and 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 prescription drugs UMP covers" section of your certificate of coverage for details.

Specific services and supplies

UMP may cover some supplies through the medical benefit and other supplies under the prescription drug benefit. See your certificate of coverage for more information on how to file a claim for specific services and supplies.

 Need help?

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

Centers of Excellence and Washington State Prescription Services do not provide BlueCross BlueShield services and are separate companies solely responsible for their products/services.

VSP is a separate company that provides vision services.