Complaints and appeals procedures

Your plan’s current Certificate of Coverage (benefits book) explains the entire process in the “Complaint and Appeal Procedures” section.

View your Certificate of Coverage

Appeals and complaints: What are they and how can I submit one?

I am a UMP member and am concerned with how UMP handled a claim or other issue. What can I do about it?

Contact UMP by phone

We suggest you try calling first. Many issues can be resolved over the phone. If you would like to send a written appeal, see “How to submit an appeal” below.

Medical services

Regence Customer Service
Phone: 1-888-849-3681
TTY: 711

Prescription drugs

Washington State Rx Services
Phone: 1-888-361-1611
TDD: 1-800-433-6313

Eligibility, enrollment, premiums

PEBB Program
Phone: 1-800-200-1004
TTY: 711

Dissatisfaction with out-of-network-provider

Washington State Department of Health
Phone: 360-236-4700 
TTY: 711

Is my issue a complaint (grievance) or an appeal?

Generally, an appeal is when you think the plan paid less for a claim than it should have, or didn’t cover a service you think it should have. Complaints are about quality of service (such as UMP Customer Service, or how you were treated by a provider). See more examples.

If you can’t determine if your issue is a complaint or appeal, do your best to explain the issue in your letter and send to the appropriate place as listed under “Where do I send an appeal or complaint?” below.

Why does it matter if it’s an appeal or not?

Complaints and appeals are handled differently by the plan. A complaint will be forwarded to whomever can best resolve or respond to your issue. For example, if your complaint is about…

  • How a particular drug is covered: Washington State Rx Services
  • How much the plan pays for a medical service: Regence (UMP medical administrator)
  • Your premium, eligibility, or enrollment: PEBB Program
  • How a healthcare provider treated you:
    • If preferred/network: Regence
    • If out-of-network/nonpreferred: Washington State Department of Health

Appeals are handled more formally than complaints. First- and second-level appeals are handled by the plan (Regence for medical services, Washington State Rx Services for prescription drugs). Independent (external) reviews are handled by outside companies that specialize in medical reviews and are contracted with the state but have no connection to UMP or the Health Care Authority.

Appeals are also subject to strict deadlines (see “What are the deadlines to send an appeal?” below). If you submit your appeal after the deadline, it will not be reviewed. While it’s a good idea to submit a complaint as soon as possible, there isn’t a formal deadline to do so.

How to submit an appeal

You may call the plan first. Some issues can be handled over the phone, saving you time and hassle. Or you can just submit your appeal in writing or on the phone if the issue is not resolved to your satisfaction.

If you submit your appeal on the phone and want a written response, you need to say that during your call. It may be in your best interests to send a written appeal, as you can make sure that your explanation of what you want is clear and that you include all relevant information. See more about information you should include in your appeal.

Where do I send an appeal or complaint?

Note: If you are appealing services related to the Center of Excellence (COE) Program for knee and hip replacement, send your appeal to Premera at the address below. Do not send it to Regence. You cannot appeal to the plan a decision by your Virginia Mason provider that you are not medically appropriate for the Program. Review your Certificate of Coverage for more information about the COE Program.

Send first-level appeals and complaints about medical services to:

Regence
Fax: 1-877-663-7526
Phone: 1-888-849-3681
TTY: 711
Business hours: Monday-Friday 7 a.m. to 5 p.m. Pacific Time (PT)
Mail: Uniform Medical Plan
PO Box 2998
Tacoma, WA 98401-2998

Send first-level appeals and complaints about prescription drugs to:

Washington State Rx Services
Fax: 1-866-923-0412
Phone: 1‑888‑361‑1611
TDD: 1-800-433-6313
Business hours: Monday-Friday 7:30 a.m. to 5:30 p.m. PT
Mail: Washington State Rx Services
Attn: Appeals
PO Box 40168
Portland, OR 97240-0168

Send first-level appeals and complaints about the COE Program to:

Premera Blue Cross
Phone: 1-855-784-4563
Business hours: Monday-Friday, 7 a.m. to 5 p.m. PT
Mail: Eligibility Appeals
Attn: Appeals Department - MS 123
PO Box 91102
Seattle, WA 98111-9102

Send second-level appeals to the contact information included in your first-level appeal response letter. Independent (external) review requests should be sent to the address in the second-level appeal response letter.

It is important to send your appeal to the right place. Sending it elsewhere could result in delays, even denial, due to the plan not receiving your appeal by the deadline. Since the plan must respond within 30 calendar days, a delayed receipt may mean the plan doesn’t have time to investigate your issues. Make sure you respond directly to any address or name inserted in a letter or other response from the plan.

Why can't I email the plan? Due to strict confidentiality rules, we cannot use regular email for appeals or communicating about any personal health issues. Use the secure messaging service in your Regence account for medical appeals and complaints. You will need to call or write about prescription drug complaints or appeals.

What are the deadlines to send an appeal?

Your deadlines

You must send your initial appeal request (first-level appeal) no later than 180 days after you receive notice of the action leading to the appeal. See examples of appeals.

Subsequent appeal levels (second-level and external/independent review) are also subject to the 180-day deadline, counted from the date of the response letter of the previous appeal level.

The plan’s deadlines: When can I expect to hear back?

The plan is required to respond to first- and second-level appeals within 14 to 30 calendar days of receiving the appeal request. If the plan needs more time to make a decision, usually to request more information such as medical records, the plan will ask for your permission to extend the deadline.

Certain appeals have shorter time limits:

  • Expedited (see “What is an expedited appeal?” below).
  • Experimental services: If the claim denial was based on a determination that the service, drug, or device is experimental or investigational, the appeal decision will be made within 20 business days.

What is an expedited appeal?

“Expedited” applies only to appeals, not complaints. An expedited appeal replaces the first- and second-level appeals. An expedited appeal is eligible for a 72-hour turnaround by the plan only when your provider determines you need a medication immediately that isn’t covered, or that the usual 30-day timeline could adversely affect your life, health, or ability to regain maximum function, or would subject you to severe pain that cannot be adequately managed without the disputed care or treatment. See more about what qualifies as an expedited appeal.

Expedited appeals must be requested by your provider by fax or phone only:

Medical services
Fax:
1‑877‑663‑7526 (providers only)
Phone: 1-888-849-3681
TTY: 711

Prescription drugs
Fax: 1‑866‑923‑0412
Phone: 1‑888‑361‑1611
TDD: 1-800-433-6313

What if I want someone else to communicate with the plan on my behalf?

Due to laws about the confidentiality of personal health information, we need written permission from you to communicate with anyone else about your appeal or complaint. If someone without permission calls or sends us a letter appealing on your behalf, we will process the appeal, but will respond only to the member or subscriber. See more about how to designate an authorized representative.