Preferred vs. out-of-network providers
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You get the most from your plan when you choose a preferred provider. Here’s why:
- You pay 15 percent of the allowed amount for most services after you pay your medical deductible (UMP Classic) or deductible (UMP CDHP).
- You pay nothing for covered preventive care services and covered immunizations.
- These provider cannot balance bill you.
- You will not have to file a claim if UMP is your primary coverage.
Alert: Some providers are preferred at one practice location but not another. Please call UMP Customer Service at 1-888-849-3681 (TRS: 711) if you have any questions about the network status of a provider at a specific location.
An approved network waiver allows the plan to pay for services provided by an out-of-network provider at the network rate. You may request a network waiver only when you do not have access to a preferred provider able to provide medically necessary services within 30 miles of the patient’s residence. 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.
Some hospital-based physicians (such as, but not limited to, anesthesiologists and emergency room doctors) who work in a preferred hospital, or other preferred facility, may not be preferred providers.
If a participating or out-of-network provider bills separately from the hospital, you will pay 40 percent of the allowed amount. For out-of-network providers, you may also be balance billed. For examples of how much you pay, see “Sample payments to different provider types” in your UMP Classic or UMP CDHP certificate of coverage.
To see the network status of anesthesiologists and emergency room doctors in Washington State hospitals, call UMP Customer Service at 1-888-849-3681 (TRS: 711).
When services are covered by Medicare, you must see providers who accept Medicare for the services to be covered by Medicare and UMP Classic. If your provider is not contracted with Medicare or has chosen to “opt out” of participating in Medicare, UMP Classic will not cover services by that provider, even if the provider is in the Regence or Blue Card network (preferred) for UMP Classic members.
Providers that “opt out” of Medicare are supposed to have you sign a “private contract” before providing services, but you are responsible for all costs even if you did not sign a contract.
Learn more about how UMP and Medicare work together in the For Medicare retirees section of the website.
- You pay 40 percent of the allowed amount for most services after you pay your medical deductible (UMP Classic) or deductible (UMP CDHP), plus 100 percent of any amount the out-of-network provider charges above the allowed amount.
- The 40 percent coinsurance you pay to out-of-network providers will not count toward your medical out-of-pocket limit (UMP Classic) or out-of-pocket limit (UMP CDHP).
- You may have to pay all charges at the time of service and then send a claim form to the plan for reimbursement.
- The provider may not request preauthorization for services that require it. As a result, payment may be delayed or denied.
- The provider may not be familiar with UMP prescription drug guidelines and prescribe drugs subject to higher cost or not covered by the plan.
Note: Payment for covered out-of-network services may be sent to you or the provider.