Policies - SEBB

Policies that affect your care

Learn about UMP policies that may affect your coverage or care.

 Pre-authorization

Pre-authorization is plan approval for coverage of specific services, supplies, or prescription drugs before they are provided to the member. Your provider must request a pre-authorization for services on the UMP pre-authorization lists.

The plan must pre-authorize some medical services and supplies to determine whether the service or supply meets the plan’s medical necessity criteria to be covered. The fact that a service or supply is prescribed or furnished by a provider does not, by itself, make it a medically necessary covered service. A change after the plan has approved a pre-authorization request, including, but not limited to, a change of provider or different/additional services, requires you to submit a new pre-authorization request and for the plan to approve it.

Pre-authorization is not a guarantee of coverage. If you or your provider do not receive pre-authorization for certain medical services or prescription drugs, the plan may deny the claim.

Pre-authorization helps you:

  • Understand your treatment options and any related risks
  • Ensure that you'll have insurance coverage for a procedure, treatment, or service
  • Avoid inappropriate or unnecessary medical treatment
  • Save unnecessary out-of-pocket costs by guiding you to the approved service or vendor

Visit the Claims & appeals page to learn how to appeal the denial of a pre-authorization request before receiving services.

Which medical services require pre-authorization?

Your provider should know which procedures require pre-authorization and can submit a pre-authorization request on your behalf. If a provider does not get pre-authorization before treating you, your plan will not cover those costs and the provider may bill you for that treatment. The plan does not approve or deny pre-authorization for services that are not on the UMP pre-authorization lists.

See what services require pre-authorization.

To learn more about pre-authorization for medical services, you can also read the Limits on plan coverage section in your plan's certificate of coverage or call UMP Customer Service.

Pre-authorization for prescription drugs

Your prescription drug benefits are managed by Washington State Rx Services. For information on pre-authorization for prescription drugs covered under your prescription drug benefit, visit Prescription drugs, contact Washington State Rx Services, or check the UMP Preferred Drug List. Information on pre-authorization for drugs covered under your medical benefit is discussed below.

How long does pre-authorization take?

The plan will notify you in writing within 15 calendar days of the plan receiving the pre-authorization request whether the request has been approved, denied, or if more information is needed to make a decision.

If additional information is requested:

  • You are allowed up to 45 calendar days from the date on the letter to submit the information requested.
  • You will be notified in writing of the decision within 15 calendar days from either the plan receiving the additional information or the end of the 45-day period if no additional information is received.

If you or your provider believes that waiting for a decision under the standard time frame could place your life, health, or ability to regain maximum function in serious danger, your provider should notify the plan by phone or fax, as a shorter time limit may apply. This is also known as an expedited pre-authorization request. Regence BlueShield will decide on your expedited pre-authorization request within 72 hours of receipt.

How are “pre-authorization” and “plan notification” different?

“Pre-authorization” means your provider must request that UMP cover a service on the UMP pre-authorization lists, and the plan sends either an approval or denial of coverage. If the plan does not approve services that require pre-authorization before the services are provided, the plan may deny coverage.

“Plan notification” means that your provider must contact the plan to let us know when you receive services. Notification is usually done by the facility at the time you receive these services.

 Health Technology Clinical Committee

The Washington State Health Technology Clinical Committee (HTCC) was created to make coverage determinations for selected health technologies based on the available scientific evidence. The purpose of this committee is to ensure medical treatments and services paid for with state health care dollars are safe and proven effective.

The HTCC is an independent committee of health care practitioners that reviews evidenced-based reports and makes a determination if the state should pay for select medical devices, procedures, or tests.

Under state law, the plan must comply with an HTCC determination. See your plan’s certificate of coverage for a list of HTCC services.

Learn more about the HTCC or see the HTCC’s current and past health technology reviews.

 Clinical policies

Learn about UMP policies for transgender services, ABA services (autism spectrum disorder), and opioids.

 Drugs covered under UMP medical benefits

UMP covers certain drugs under your medical benefit, usually called provider-administered drugs. These drugs typically require a health care provider to administer them, which makes them different from drugs that you pick up at your retail pharmacy or have delivered to your home. You may receive a provider-administered drug from a standalone infusion site, doctor’s office, at your home (home infusion), or at some outpatient hospital facilities. Keep reading to learn more about how to access provider-administered drugs for specific diseases, find out if a certain provider-administered drug is preferred, review pre-authorization requirements, and understand why it’s important to make sure you are obtaining your provider-administered drug at a preferred site of care.

Provider-administered drug treatment options

Regence BlueShield can help you manage the different treatment options available under the prescription drug benefits and medical benefits for specific diseases. Use these guides to help you choose the most appropriate therapy, when there are options under both the medical benefits and prescription drug benefits:
Multiple sclerosis
Chronic inflammatory diseases (e.g. rheumatoid arthritis, Crohn's disease, etc.)

Medical Preferred Drug List

The UMP Medical Preferred Drug List includes preferred and non-preferred provider-administered drugs for certain drug classes available through the medical benefit. This list will help you and your provider identify drugs that are safe and effective, and have the greatest savings for you.

Pre-authorization

Some provider-administered drugs need pre-authorization to determine whether they are medically necessary and meet clinical criteria, or the plan will not cover them. Find out if your drug needs pre-authorization and review coverage criteria by calling UMP Customer Service or by checking online. If your drug needs pre-authorization, please contact your provider. They will obtain pre-authorization on your behalf.

Infusion drug site-of-care program (Does not apply to UMP Plus members)

Some provider-administered drugs can be administered in more than one place. Preferred sites of care can offer more flexibility, comfort, convenience, and reduced cost. If you receive infusion drugs and have UMP Achieve 1, UMP Achieve 2, or UMP High Deductible, be sure to get treatment at an approved site of care. Approved sites of care can include standalone infusion sites, doctor’s offices, home infusion, and some outpatient hospital facilities. Infusion drugs must be pre-authorized by the plan before you get treatment. Call UMP Customer Service for a list of drugs included in the site-of-care program or for help finding an approved site of care near you.

 Additional resources

Getthefactsrx.com features the Starts with One campaign, which is designed to inform and educate young adults, their parents, and older adults about the dangers of prescription drug misuse and the importance of safe storage, use, and disposal. This campaign is funded by the Washington State Health Care Authority (HCA).

WA Tribal Opioid Solutions provides educational resources for Tribes and tribal organizations working to address opioid prevention, overdose response and treatment. This campaign is funded by HCA and SAMHSA State Opioid Response, and informed by recommendations from tribal leaders.