Complaints and appeals procedures

For complete information, read the “Complaint and Appeal Procedures” section of your certificate of coverage (benefits book).

View your certificate of coverage

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

We suggest calling UMP 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.

Is my issue a complaint 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 (or grievances) are about quality of service (such as UMP Customer Service, or how you were treated by a provider).

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.

Appeals are subject to strict deadlines (see "How do I submit an appeal?" below). While it's a good idea to submit a complaint as soon as possible, there isn't a formal deadline to do so.

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 (UMP prescription drug administrator)
  • How much the plan pays for a medical service: Regence (UMP medical administrator)
  • Your premium, eligibility, or enrollment: PEBB Program
  • How a health care 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. They are contracted with the state but have no connection to UMP or the Health Care Authority.

You may request an external or independent review when the denial is based on the plan's decision to deny, modify, reduce, or terminate coverage of (or payment for) a health care service.

To qualify for an independent review, you must have already gone through both a first- and second-level appeal (or expedited appeal) based on one of the issues listed above. You may request an external or independent review in the following situations:

  • If the plan has exceeded the timelines for response to your appeal without good cause and without reaching a decision.
  • If you are dissatisfied with the decision of your second-level appeal (or expedited appeal).
  • If the plan has failed to strictly adhere to the requirements of the appeals process.

You must request an independent review no more than 180 days after the date of the letter responding to your second-level appeal (or expedited appeal). Only the member or an authorized representative can request an independent review.

Requesting an independent review

To request an independent review, contact the plan at:

  For medical services For prescription drugs
Mail Uniform Medical Plan
PO Box 2998
Tacoma, WA 98401-2998
Washington State Rx Services
Attn: Appeals
PO Box 40168
Portland, OR 97240-0168
Phone 1-888-849-3681 (TRS: 711) 1-888-361-1611 (TDD: 1-800-433-6313)
Fax 1-877-663-7526 1-866-923-0412

The plan will send the relevant information and correspondence to the Independent Review Organization (IRO). 

Additional legal options

You are required to have exercised the opportunity to seek IRO review of the Plan’s decision before you are authorized to bring a cause of action in court against the Plan or the Health Care Authority. The IRO decision is binding on both the Plan and you except to the extent that other remedies are available under state or federal law. If you prevail at the IRO level, the Plan must provide benefits (including by making payment on the claim) following the IRO’s decision without delay, regardless of whether the Plan intends to seek judicial review of the IRO’s decision and unless and until there is a judicial decision otherwise.

Appeals are also subject to strict deadlines (see “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 do I 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 and documentation.

Though it is not required, it may help you to include the UMP Appeals and Grievance form with your written appeal. It explains what information should be included, and it lists the address and fax number where they should be submitted.

Information to provide with an appeal

  • The subscriber’s full name (the name of the employee or retiree covered by the plan).
  • The patient’s full name.
  • 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. Because of the time limits on deciding appeals, getting this information in advance will help us make the most accurate decision on your case.

You may send in your appeal without including all of this information, but sending complete information will help the plan make the best-informed decision.

Where to send an appeal or complaint

Note: If you are appealing services related to the Center of Excellence (COE) Program, send your appeal to Premera at the address below. Do not send it to Regence. You cannot appeal to the plan a decision made 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 5 a.m. to 8 p.m. and Saturdays 8 a.m. to 4:30 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 BlueCross
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 discussing 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.

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.

Here are some examples of when the 180-day appeal time limit begins:

  • Dissatisfaction with how much the plan paid on a claim/service: The date you received notice from the plan about how your claim was paid. (Note that the date of a provider bill is irrelevant.)
  • Appealing a preauthorization denial: The date of the response from the plan denying the preauthorization request.
  • Coverage of a prescription drug: The date the drug was initially prescribed.

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.
  • 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 in one of the following situations:

  • When your provider determines you need a medication immediately that isn’t covered.
  • When your provider determines 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.

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 (providers only*)
Phone: 1‑888‑361‑1611
TDD: 1-800-433-6313

*Providers must state that the request is urgent in order for it to be expedited.

Can someone else communicate with the plan for me?

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.

To authorize release of protected health information, you must complete an Authorization to Disclose Protected Health Information form. There are separate forms for medical and prescription drug appeals.

You may download the form for medical appeals or call UMP Customer Service at 1-888-849-3681. You may also download the form for prescription drug appeals, or call Washington State Rx Services at 1-888-361-1611. Send the form to the address listed on it. UMP cannot share information until we receive the completed form.

Contact

Medical services

UMP Customer Service
Phone: 1-888-849-3681
TRS: 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
TRS: 711

Dissatisfaction with out-of-network-provider

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