2021 UMP High Deductible (SEBB) Certificate Of Coverage - Wa
2021 UMP High Deductible (SEBB)Certificate of CoverageSelf-insured by the State of Washington·Effective January 1, 2021Printed under the direction of the Washington State Health Care Authority School Employees Benefits Board (SEBB)HCA 20-0099 (7/20)
Directory: medical servicesContact type anddescriptionContact informationUMP Customer Serviceand generalcorrespondenceCall: 1-800-628-3481 (TRS: 711)Monday-Friday: 5 a.m. to 8 p.m.; Saturday: 8 a.m. to 4:30 p.m. (Pacific)Chat live: Sign in to your Regence account at regence.com to chat liveMonday-Friday: 7 a.m. to 5 p.m. (Pacific)Email: Send secure email via your Regence account at regence.comIf you are outside the U.S. and you have questions about your benefits andcoverage, you can use email, chat live, or Skype to contact UMP CustomerService. You may request to have a customer service representative callyou at a scheduled time during normal business hours.If you are outside the U.S. and need to find a local provider, make anappointment or be hospitalized, call Blue Cross Blue Shield Global Coreat 1-800-810-2583 or call collect at 1-804-673-1177, 24 hours a day, 7days a week.Network providerdirectoryCall: 1-800-628-3481 (TRS: 711)Monday-Friday: 5 a.m. to 8 p.m.; Saturday: 8 a.m. to 4:30 p.m. (Pacific)Chat live: Sign in to your Regence account at regence.com to chat liveMonday-Friday: 7 a.m. to 5 p.m. (Pacific)Provider Nurse line (Advice 24)Call: 1-800-267-6729 (TRS: 711)Access to a nurse anytime24 hours a day, 7 days a weekMedical appeals,complaints andgrievancesCall: 1-800-628-3481 (TRS: 711)Monday-Friday: 5 a.m. to 8 p.m.; Saturday: 8 a.m. to 4:30 p.m. (Pacific)Chat live: Sign in to your Regence account at regence.com to chat liveMonday-Friday: 7 a.m. to 5 p.m. (Pacific)Fax: 1-877-663-7526Secure Online Account: Sign in to your Regence account at regence.comand navigate to Appeals to submit an appeal onlineEmail: memberappeals@regence.comMail:UMP Member AppealsRegence BlueShieldPO Box 91015Seattle, WA 98111-91152021 UMP High Deductible (SEBB) Certificate of Coverage1
Contact type anddescriptionContact informationPreauthorizationCall: 1-888-849-3682 (TRS: 711)For providers submittingmedical servicepreauthorization requestsMonday-Friday: 7 a.m. to 5 p.m. (Pacific)Access to medicalclaimsVisit: Sign in to your Regence account at regence.comClaims mailing addressFax: 1-877-357-3418For members submittingmedical service claimsMail:HealthEquityCall: 1-844-351-6853 (TRS: 711), 24 hours, 7 days a weekHealth savings account(HSA) trusteeVisit: learn.healthequity.com/sebbMedicareCall: 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048)Fax: 1-877-663-7526Visit: availity.comRegence BlueShieldPO Box 1106Lewiston, ID 83501-110624 hours, 7 days a weekVisit: medicare.gov or MyMedicare.govEligibility, enrollment,and address changesEmployees: Contact your payroll or benefits officeContinuation Coverage: Call the SEBB Program: 1-800-200-1004(TRS: 711)Monday-Friday: 8 a.m. to 4:30 p.m. (Pacific)Visit: hca.wa.gov/erbTobacco cessationservicesAmerican Cancer Society’s Quit for Life programSee page 7224 hours, 7 days a weekCall: 1-866-784-8454Visit: quitnow.netHCA is committed to providing equal access to our services. If you need an accommodation, or requiredocuments in another format, please contact the following: Employees: Your payroll or benefits office. SEBB Continuation Coverage members: Call us at 1-800-200-1004 (TRS: 711).2021 UMP High Deductible (SEBB) Certificate of Coverage2
Directory: prescription drug servicesContact type and descriptionContact informationPrescription drugsWashington State Rx Services (WSRxS)Contact customer service, locatenetwork pharmacies, askprescription drug questions,access prescription drug claimsCall: 1-888-361-1611 (TRS: 711)Network mail-order pharmacyPostal Prescription Services (PPS)Order new prescriptions andrefills, check order status, manageprescriptions, track your packageCall: 1-800-552-6694Monday-Friday: 7:30 a.m. to 5:30 p.m. (Pacific)Available outside these hours with limited services.Visit: Find a link to your WSRxS account y-Friday: 6 a.m. to 6 p.m. (Pacific)Saturday: 9 a.m. to 2 p.m. (Pacific)Providers fax: 1-800-723-9023Mailing a prescription order:Postal Prescription ServicesPO Box 2718Portland, OR 97208-2718Visit: Sign in to your PPS account at ppsrx.comNetwork specialty pharmacyArdon HealthOrder new prescriptions andrefills for specialty drugsCall: 1-855-425-4085 (TRS: 711)Monday-Friday: 8 a.m. to 7 p.m. (Pacific)Saturday: 8 a.m. to 12 p.m. (Pacific)Closed Sundays and all major holidaysProviders fax: 1-855-425-4096Visit: ardonhealth.comPrescription drug paper claims,complaints and appealsWSRxSSee instructions for submitting aclaim on page 114Monday-Friday: 7:30 a.m. to 5:30 p.m. (Pacific)Call: 1-888-361-1611 (TRS: 711)Fax claims to: 1-800-207-8235Fax appeals to: 1-866-923-0412Email: Send secure email through your WSRxS account WSRxSPO Box 40168Portland, OR 97240-0168Visit: Find claim forms on the HCA website athca.wa.gov/ump-forms-pubs2021 UMP High Deductible (SEBB) Certificate of Coverage3
Contact type and descriptionContact informationPrescription drugpreauthorizationWSRxSFor providers and pharmacistssubmitting prescription drugpreauthorization requestsMonday-Friday: 7:30 a.m. to 5:30 p.m. (Pacific)Call: 1-888-361-1611 (TRS: 711)Fax: 1-800-207-8235Visit: covermymeds.com (see page 88)2021 UMP High Deductible (SEBB) Certificate of Coverage4
Table of contentsDirectory: medical services . 1Directory: prescription drug services . 3Online services . 10How to use this certificate of coverage . 11If you still have questions . 11About UMP High Deductible . 12Features of UMP High Deductible . 12Finding a health care provider . 13Sample payments to different provider types . 14How to find a preferred provider . 15Covered provider types . 16When you do not have access to a preferred provider: network waiver . 16When and how to request a network waiver . 17How an HSA works . 18Out-of-area services . 18Services received outside the United States . 20What you pay for medical services . 21Deductible . 21Coinsurance. 23When you pay . 24Health savings account (HSA) . 24Out-of-pocket limit . 25Summary of services and payments . 26Deductible and limits . 26Types of services . 27What else you need to know . 30Benefits: what the plan covers. 30Guidelines for coverage . 30Health Technology Clinical Committee (HTCC) . 31Summary of benefits . 34List of benefits . 36Acupuncture . 36Ambulance . 36Applied Behavior Analysis (ABA) Therapy . 372021 UMP High Deductible (SEBB) Certificate of Coverage5
Autism treatment . 38Bariatric surgery . 38Behavioral health . 38Breast health screening tests . 40Care Gap Closure Program . 41Care management . 41Chiropractic physician services . 42Dental services . 42Diabetes care supplies . 44Diabetes Control Program . 44Diabetes education. 45Diabetes Prevention Program (DPP). 45Diagnostic tests, laboratory, and x-rays . 45Dialysis . 46Durable medical equipment (DME), supplies, and prostheses . 46Emergency room . 48End-of-life counseling . 48Family planning services. 49Foot care, maintenance . 50Genetic services . 50Headaches, chronic migraine or chronic tension type . 50Hearing care (diseases and disorders of the ear) . 51Home health care . 52Hospice care . 52Hospital services . 53Infusion drug site of care program . 54Joint replacement surgery, knees and hips in the Centers of Excellence (COE) Program . 55Knee arthroplasty, total . 58Mammogram and Digital Breast Tomosynthesis (DBT) . 58Massage therapy . 59Mastectomy and breast reconstruction . 59Mental health . 59Naturopathic physician services . 59Nurse line . 60Nutrition counseling and therapy . 602021 UMP High Deductible (SEBB) Certificate of Coverage6
Obstetric and newborn care . 60Office visits . 62Orthognathic surgery . 62Pain and joint management, interventional . 62Prescription drugs . 62Preventive care . 62Radiology . 65Second opinions . 65Skilled nursing facility . 66Sleep therapy . 66Spinal and extremity manipulations . 67Spinal injections . 67Spinal surgery . 67Spine care in the Centers of Excellence (COE) Program . 67Substance use disorder . 70Surgery . 70Temporomandibular joint (TMJ) treatment . 71Therapy: Neurodevelopmental, occupational, physical, and speech. 71Tobacco cessation services . 72Transgender services . 73Transplants. 74Urgent care . 74Virtual care . 74Your prescription drug benefit. 76The UMP Preferred Drug List . 76How UMP decides which prescription drugs are preferred . 77What you pay for prescription drugs . 78Where to buy your prescription drugs . 81Guidelines for prescription drugs UMP covers . 84Limits on your prescription drug coverage . 87What to do if the plan denies coverage . 92Prescription drugs UMP does not cover . 92Limits on plan coverage . 93Preauthorizing medical services . 93General information from UMP Customer Service . 962021 UMP High Deductible (SEBB) Certificate of Coverage7
What the plan does not cover . 97If you have other HDHP coverage . 107Coordination of benefits . 107Contact UMP and WSRxS . 107Who pays first . 108Billing & payment: filing a claim . 112Submitting a claim for medical services . 112Submitting a claim for prescription drugs . 114False claims or statements . 115Complaint and appeal procedures . 116What is a complaint or grievance?. 116How to submit a complaint or grievance . 116What is an appeal? . 116The appeals process . 117Complaints about quality of care . 120Appeals related to eligibility. 121Where to send complaints or appeals. 121When another party is responsible for injury or illness . 121Occupational injury or illness (workers’ compensation) claims . 122Legal rights and responsibilities . 122Fees and expenses . 123Services covered by other insurance . 124Motor vehicle coverage . 124Future medical expenses . 124Eligibility and enrollment . 124Eligibility . 124Enrollment . 126Options for continuing SEBB medical coverage . 134Option for coverage under Public Employees Benefits Board (PEBB) retiree insurance . 134Transitional continuation coverage . 135Family and Medical Leave Act of 1993 . 135Paid Family Medical Leave Act . 135General information .
Jan 01, 2021 · Contact information . UMP Customer Service ; and general . correspondence: Call: 1-800-628-3481 (TRS: 711) Monday
your health plan and other insurance options by attending one of the SEBB Program benefits fairs. All are from 4 to 7 p.m., except Pasco, which is 3 to 6 . hca.wa.gov/sebb-employee. hca.wa.gov/sebb-employee. sebb.naviabenefits.com. page 8. hca.wa.gov/sebb-oe. 6 Who to contact for help
Uniform Medical Plan (UMP), administered by Regence BlueShield (for medical questions) UMP Achieve 1, Achieve 2, High Deductible, UMP Plus . hca.wa.gov/sebb-employee to explore your options: Virtual be
Uniform Medical Plan (UMP), administered by Regence BlueShield (for medical questions) UMP Achieve 1, Achieve 2, High Deductible, UMP Plus: . hca.wa.gov/sebb-employee. to explore your options: Virtual benefi ts fair
hca.wa.gov/ump-pebb-coc for full benefit details. To get the most out of your . Service at 1-888-849-3681 (TRS: 711). Hearing aid benefit The hearing aid benefit for UMP members is changing. Starting in 2021, you pay 0 of the allowed amount every five calendar . full preventive care list on HealthCare.gov . 4 2021 UMP (PEBB) Open .
, select “Forms & publications” in the blue bar at the top of the page, and type “UMP: pr
Kaiser WA SoundChoice Kaiser WA CDHP UMP Classic UMP Plus UMP Select UMP CDHP. Non-Medicare Retirees & Split Accounts. 4 Split Account is defined as non-Medicare and Medicare members enrolled under one Subscriber account. For Example: . Sara.Whitley@hca.
limited to a single enrollment in medical and dental plans (PEBB Program) or medical, dental, and vision (SEBB Program). If they are a PEBB employee who waives PEBB medical and dental for SEBB medical, they must also enroll in SEBB dental and vision. Relationship to subscriber 1 This field is required for health care services.
API and DNV codes describe slightly different approaches to assess the axial bearing capacity of a pile. These codes provide guidline for the calculation of pile length in common soil conditions such as clay (cohesive) or sand (cohesionless). The assessment also depends on the type of soil information available i.e. laboratory test results showing soil properties such as undrained shear .
