Submitting a claim

When Uniform Medical Plan (UMP) is your primary insurance and your provider is preferred (called "network" for UMP Plus), you don't need to submit claims; the provider will do it for you.

But there are some circumstances where you will need to submit a claim to the plan. If you have a question about whether your provider's office has submitted a claim, log in to your account at regence.com or call UMP Customer Service at 1-888-849-3681.

For complete information, read "Billing & Payment: Filing a Claim" in your certificate of coverage.

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Medical claims

When do I need to submit a medical claim?

You may need to submit a claim to UMP for payment if:

Out-of-network providers may submit a claim on your behalf; ask the provider.

Tip: If you get a vaccine (including a flu shot) from an out-of-network provider, you must submit the claim to Regence as a medical claim. Member-submitted vaccine claims sent to Washington State Rx Services will be denied.

How do I submit a medical claim?

To submit a claim yourself, you'll need to fill out and mail these documents:

  1. The Medical Claim Form.
  2. An itemized bill from your provider that describes the services you received and the charges. The following information must appear on the provider's itemized bill for the plan to consider the claim for payment:
    • Patient's name and plan ID number, including the alpha prefix (three letters before ID number).
    • Description of the injury or illness. Ask your provider to include procedure codes (or CPT codes) and diagnosis codes when possible.
    • Date and type of service.
    • Provider's name, address, and phone number. Ask your provider to give you either their National Provider Identification (NPI) or their Tax ID.
    • For ambulance claims, please also include the ZIP code where the patient was picked up and the ZIP code where they were taken.
  3. If UMP pays second, 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. 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.

Reimbursement for services received from an out-of-network provider may be sent to the provider or to you in the form of a check listing both you and the provider as payees. When you submit claims for services you have already paid for in full, include evidence of this payment (such as a credit card receipt or a copy of a cashed check). This evidence will make sure payment is issued only to you.

Always make copies of your documents for your records. Then, mail both the claim form and the provider's claim document (or bill) to:

Regence BlueShield
Attn: UMP Claims
PO Box 1106

Lewiston, ID 83501-1106
(or by fax to: 1-877-357-3418)

Call Customer Service at 1-888-849-3681 if you have a question about the status of your claim.

Tip: If you purchase contact lenses or eyeglasses from an out-of-network provider that doesn't bill your plan, you will need to submit a claim for reimbursement using the Vision Claim Form.

Important information about submitting medical claims

You or your provider must submit claims within 12 months of the date you received health care services; this is called the "timely filing" deadline. The plan will not pay claims submitted more than 12 months after the date of service.

If you or a family member have other health care coverage that pays first, and that primary plan delays payment on a claim, you should still submit the claim to UMP within 12 months to prevent denial. See the "If You Have Other Medical Coverage" section in your 2017 certificate of coverage for information on how UMP coordinates benefits with other plans.

For information about submitting claims for services received internationally, visit Access coverage while traveling.

TIP: To prevent errors and delays in claim processing, always tell your providers right away if your coverage changes.

Claims Reimbursement

Most of the time, the plan will pay preferred providers directly. For claims submitted by you or an out-of-network provider, the plan will determine whether to pay you, the provider, or both you and the provider.

For a child covered by a legal qualified medical child support order (QMCSO), the plan may pay the custodial parent or legal guardian of the child.

Claims Determinations

You will be notified 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. Notification will include an explanation why an extension is necessary and when the plan expects to take action 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 as well as why it is needed.

If the plan asks you for more information, you will be given at least 45 days to provide it. If the plan doesn't receive the information requested within the time allowed, the claim will be processed based on the information available, which may result in a denial of the claim.

Prescription drug claims

You must submit prescription drug claims within 12 months of purchase. Claims for prescription drugs submitted more than 12 months after purchase will not be paid.

You may need to submit your own prescription drug claim to Washington State Rx Services for reimbursement if you:

  • Purchase drugs at a non-network pharmacy.
  • Fail to show your ID card at a network pharmacy.
  • Get a prescription from a mail-order or internet pharmacy other than PPS, the plans' network mail-order pharmacy.
  • Have other prescription coverage that pays first and UMP is secondary.

You can download the prescription drug claim form, or call Washington State Rx Services at 1-888-361-1611. Send the completed claim form and your pharmacy receipt(s), to:

Washington State Rx Services
Attn: Pharmacy Claims
PO Box 40168
Portland, OR 97240-0168
Fax: 1-800-207-8235

It's a good idea to keep copies of all your paperwork for your records.

Tip: Foreign claims for prescription drugs must be translated into English with specific services, charges, drugs and dosage documented, and you must tell us the currency exchange rate. The plan does not pay for this documentation or translation.

 When you submit a prescription drug claim to Washington State Rx Services, the plan pays the claim based on the following rules, no matter where you purchased the drug:

  • The plan pays based on the allowed amount. If the pharmacy charges you more than the allowed amount, you will pay your usual coinsurance (and deductible if applicable), plus the difference between what the plan paid and the pharmacy's charge.
  • UMP Classic pays all prescription drug claims, including non-network, based on coinsurance.
  • UMP CDHP pays all prescription drug claims based on coinsurance.
  • UMP Plus pays all prescription drug claims based on coinsurance.
  • If your claim exceeds the quantity limit allowed by the plan or the maximum days' supply, the plan will pay only for the amount of the drug up to the quantity limit or maximum days' supply.
  • If you receive a refill before 84 percent of the last supply you received should have been taken, the plan will not pay for it. This is called a "refill too soon."

Contact

Questions about medical claims

UMP Customer Service
Phone: 1-888-849-3681
TTY: 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)

Questions about prescription drug claims

Washington State Rx Services
Phone: 1-888-361-1611
TDD: 1-800-433-6313
Business hours: customer service is available 24 hours a day, 7 days a week

Questions about claims for services outside the U.S.

BlueCard Worldwide
Phone
: 1-800-810-BLUE (2583), or call collect 1-804-673-1177