Complaints and appeals procedures

For complete information, read the “Complaint and appeal procedures” section of your certificate of coverage.

View your certificate of coverage

What is a complaint?

A complaint is different from an appeal.  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.
  • Dissatisfaction with service provided by the health plan.

Note: If your issue is regarding denial of payment or nonprovision 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 does not resolve your complaint, you may submit your complaint:

  • Over the phone: If you want a written response, you must request one.
  • In writing: By mail, fax, or email 

Make sure you submit your complaint to the right party. While it's a good idea to submit a complaint as soon as possible, there isn't a formal deadline to do so.

You will 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.

Complaints about quality of care

For complaints or concerns about the quality of care you received from preferred (network for UMP Plus) providers only, call UMP Customer Service at 1-888-849-3681 (TRS: 711) or send a secure email through your Regence account.

For complaints or concerns about the quality of care you received from any provider (including out-of-network providers):

What is an appeal?

An appeal is when you (or your authorized representative) send Regence BlueShield, Washington State Rx Services, or Premera a verbal or written request to reconsider a previous decision about:

  • Claims payment, processing, or reimbursement for health care services or supplies.
  • 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 retroactive decision to deny coverage based on eligibility. See "Appeals related to eligibility" below.
  • A preauthorization.

Tip: To learn more about authorized representatives, read the "Confidentiality of your health information" section of your plan's certificate of coverage.

Who handles complaints and appeals?

Medical, prescription drugs, Center of Excellence

  • Regence BlueShield handles medical complaints and appeals.
  • Washington State Rx Services handles complaints and appeals involving prescription drugs.
  • Premera handles appeals for services related to the Centers of Excellence Program for knee and hip joint replacement surgery and spine care. 

You can find contact information for Regence BlueShield, Washington State Rx Services, and Premera in "Where do I send appeals?" or at the bottom of this page.

Appeals related to eligibility

Appeals related to eligibility and enrollment are handled by the Public Employees Benefits Board (PEBB) Program and governed by Washington Administrative Code (WAC) chapter 182-16.

Information on how to file an appeal is available:

How does the appeals process work?

Important: Appeals procedures may change during the year if required by federal or Washington State law.

You, your treating provider, or an authorized representative may request an appeal for you. There are three parts to the appeals process: first-level appeal, second-level appeal, and independent review.

First-level and second-level appeals are part of an internal review process, while independent reviews are part of an external review process.

To understand how UMP covers services during the appeal process read the "Complaint and appeal procedures" section in your plan's certificate of coverage

If your appeal is for an urgent or life-threatening condition, see “Expedited appeals."

You may request a first-level appeal verbally or in writing no more than 180 days after you receive notice of the action leading to the appeal. Although you may request an appeal by phone or in person, putting your appeal in writing will help us make more informed decisions. If you don’t request an appeal within this time period, your appeal will not be reviewed and you will not be able to continue further appeals (second-level and independent review).

Deadlines for submitting an appeal: Deadlines are based on the first date you are notified of how a claim processed, usually when the plan sends you an Explanation of Benefits (including services that applied to the deductible or were denied). The plan does not waive deadlines based on untimely billing by your provider.

First-level appeals for medical services are handled by Regence BlueShield and first-level appeals for prescription drugs are handled by Washington State Rx Services.

Employees from Regence BlueShield and Washington State Rx Services handling the appeals will not have been involved in the initial decision you are appealing. Claim processing disputes will be reviewed by administrative staff.

Appeals that involve issues requiring medical judgment about covering, authorizing, or providing health care will be evaluated by the staff of health care professionals at Regence BlueShield or Washington State Rx Services.

If you disagree with the decisions made on your first-level appeal, you may request a second-level appeal. Second-level appeals must be submitted no more than 180 days after the date of the letter responding to your first-level appeal. If you don’t request an appeal within this time period, your appeal will not be reviewed and you will not be able to continue further appeals (independent review).

Second-level appeals for medical services are reviewed by Regence BlueShield employees, and second-level appeals for prescription drugs are handled by Washington State Rx Services. Employees from Regence BlueShield and Washington State Rx Services handling the appeals will not have been involved in, or subordinate to anyone involved in, the first-level decision. You, or your authorized representative, will be given a reasonable opportunity to provide written testimony for Regence BlueShield or Washington State Rx Services to consider

For medical service claims involving urgent care

An expedited appeal replaces the first- and second-level appeals. You can ask your provider to request an expedited appeal if the plan denies coverage for services and your provider determines that taking the usual time allowed for an appeal:

  • Could seriously 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.

Your provider must submit all clinically relevant information to the plan by phone or by fax:

  • Phone: 1-888-849-3681 (TRS: 711)
  • Fax: 1-877-663-7526 (providers only)

Regence BlueShield will decide on your expedited appeal within 72 hours of the request. If you disagree with the expedited appeal decision, your provider may request an urgent expedited independent review.

For prescription drugs

An expedited appeal replaces the first- and second-level appeals. You  or your provider may request an expedited appeal if you or your provider thinks that you need a medication immediately.

Your provider must submit all clinically relevant information to the plan by phone or by fax:

  • Phone: 1‑888‑361‑1611 (TRS: 711)
  • Fax: 1‑866‑923‑0412 (providers only)

Washington State Rx Services will decide regarding coverage of the drug within 72 hours of the request. In this case, you may choose to purchase a three-day supply at your own expense.

If Washington State Rx Services’ decision is to cover the drug, Washington State Rx will reimburse you up to the allowed amount minus the member cost-share (coinsurance and prescription drug deductible if applicable). If Washington State Rx Services decides not to cover the drug (denies the appeal), you are responsible for the full cost of the drug.

How do I file an appeal?

You can send an appeal by telephone, mail, fax, or email. Make sure you contact the right party. The plan will send confirmation upon receipt of your appeal. 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.

You may send written comments, documents, and any other information when you request an appeal. You may also request copies of documents the plan has that are relevant to your appeal, which the plan will provide at no cost. Our review will consider any information submitted to us.

Your appeal will be handled more quickly if you provide all the necessary information when you file it. 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 family member 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. Because of the time limits on deciding appeals, getting this information in advance will help us make the most accurate decision on your case.

Though it is not required, it may help you 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 written appeal. It explains what information should be included, and it lists the address and fax number where you should submit the information.

Where you send your appeal depends on if you are appealing a medical service, prescription drug, or a Center of Excellence Program decision. The table below give you contact information for each.

All times are listed as Pacific.

  Medical Services: Regence Prescription drugs: Washington State Rx Services Center of Excellence Program: Premera Blue Cross
Phone

1-888-849-3681 (TRS: 711)

  • Monday through Friday: 5 a.m. to 8 p.m. Pacific Time (PT)
  • Saturday 8 a.m. to 4:30 p.m. PT

1-888-361-1611 (TRS: 711)

  • 24 hours a day, 7 days a week

1-855-784-4563

Mail

Uniform Medical Plan
Attn: Appeals
PO Box 2998
Tacoma, WA 98401-2998

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

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

Email Secure email through your Regence account. Not available. Not available.
Fax 1-877-663-7526 1-866-923-0412 1-800-995-2430

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

First-level appeals

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. 

Deadlines for submitting an appeal are based on the first date you are notified of how a claim processed, usually when the plan sends you an Explanation of Benefits (including services that applied to the deductible or were denied). The plan does not waive deadlines based on untimely billing by your provider.

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

  • 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.

Second-level appeals

Second-level appeals must be submitted no more than 180 days after the date of the letter responding to your first-level appeal.

Independent review

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).

Note: The plan will comply with shorter time limits than those below when required by Washington State law.

First- and second-level appeals

The plan will decide on first- and second-level appeals within 14 days of receiving the appeal but may take up to 30 days unless a different time limit applies as explained below. We will request written permission from you or your authorized representative when we need an extension to the 30-day timeline, to get medical records or a second opinion.

Expedited appeals

We will decide as soon as possible but always within 72 hours when your provider determines a delay:

  • Could seriously jeopardize your life, health, or ability to regain maximum function, or
  • Would cause severe pain that could not be adequately managed without the care or treatment you are appealing.

We will notify you (or your authorized representative) of our decision verbally within 72 hours, and will mail a written notification within 72 hours of the decision.

Can I request an external review?

In some cases you may be able to request an external review by an Independent Review Organization (IRO). 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.

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.

You may request an external or independent review if you have gone through both a first- and second-level appeal (or expedited appeal) and your appeal was based on one of the issues listed above.

You may also immediately request external 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 the plan has failed to 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.

Tip: An Independent Review Organization (IRO) will conduct the external review. The plan will pay the IRO’s charges.

Requesting an independent review

To request an independent review, contact the plan at:

  For medical services For prescription drugs
Mail

Uniform Medical Plan
Attn: Appeals
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 (TRS: 711)
Fax 1-877-663-7526 1-866-923-0412

The plan—Regence BlueShield for medical services, and Washington State Rx Services for prescription drugs—will send the relevant information and correspondence to the Independent Review Organization.

 Additional legal options

You are required to have exercised the opportunity to seek Independent Review by an IRO 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.

    Contact

    Medical services

    UMP Customer Service
    Phone: 1-888-849-3681
    TRS: 711
    Business hours: Monday-Friday 5 a.m. to 8 p.m. and Saturday 8 a.m. to 4:30 p.m. Pacific time (PT)

    Prescription drugs

    Washington State Rx Services
    Phone: 1-888-361-1611
    TRS: 711
    Business hours:  24 hours a day, 7 days a week

    Center of Excellence Program

    Premera Blue Cross
    Phone: 1-855-784-4563
     

    Eligibility, enrollment, premiums

    PEBB Program
    Phone: 1-800-200-1004
    TRS: 711
    Business hours: Monday-Friday 8 a.m. to 5 p.m. PT