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for School EmployeesK–12 Charter ESDAccountable Care Network2021 UMP Plus–UW Medicine Accountable Care Network (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 20-0098 (7/20)
Directory: medical servicesContact type and descriptionContact informationUMP Plus–UW Medicine ACNContact CenterCall: 1-855-520-9400 (TRS: 711)Find network providers andrequest out -of-network consentVisit: sebb.uwmedicine.orgUMP Customer Service andgeneral correspondenceCall: 1-800-628-3481 (TRS: 711)Monday-Friday: 7 a.m. to 7 p.m. (Pacific)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 chatliveMonday-Friday: 7 a.m. to 5 p.m. (Pacific)Email: Send secure email via your Regence account atregence.comIf you are outside the U.S. and you have questions about yourbenefits and coverage, you can use email, chat live, or Skype tocontact UMP Customer Service. You may request to have acustomer service representative call you at a scheduled timeduring normal business hours.If you are outside the U.S. and need to find a local provider, makean appointment or be hospitalized, call Blue Cross Blue ShieldGlobal Core at 1-800-810-2583 or call collect at 1-804-673-1177,24 hours a day, 7 days a week.Network provider directoryCall: 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 chatliveMonday-Friday: 7 a.m. to 5 p.m. (Pacific)Provider search: ump.regence.com/go/SEBB/UMP-Plus-UWMACNNurse lineCall: 1-855-520-9400 (TRS: 711)Access to a nurse anytime24 hours a day, 7 days a week2021 UMP Plus–UW Medicine ACN (SEBB) Certificate of Coverage1
Contact type and descriptionContact informationMedical appeals, complaintsand grievancesCall: 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 chatliveMonday-Friday: 7 a.m. to 5 p.m. (Pacific)Fax: 1-877-663-7526Secure Online Account: Sign in to your Regence account atregence.com and navigate to Appeals to submit an appeal onlineEmail: memberappeals@regence.comMail:UMP Member AppealsRegence BlueShieldPO Box 91015Seattle, WA 98111-9115PreauthorizationCall: 1-888-349-3682 (TRS: 711)For providers submitting medicalservice preauthorization requestsMonday-Friday: 7 a.m. to 5 p.m. (Pacific)Fax: 1-877-663-7526Visit: availity.comAccess to medical claimsVisit: Sign in to your Regence account at regence.comClaims mailing addressFax: 1-877-357-3418For members submitting medicalservice claimsMail:Eligibility, enrollment, andaddress changesEmployees: Contact your payroll or benefits officeRegence BlueShieldPO Box 1106Lewiston, ID 83501-1106Continuation 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 cessation servicesAmerican Cancer Society’s Quit for Life programSee page 71Call: 1-866-784-845424 hours, 7 days a weekVisit: 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 Plus–UW Medicine ACN (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 115Monday-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 Plus–UW Medicine ACN (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 89)2021 UMP Plus–UW Medicine ACN (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 Plus . 12UMP Plus: High-quality care at a lower cost . 12Finding a health care provider . 12UMP Plus–UW Medicine ACN . 13Covered provider types . 16Network primary care providers . 16Network specialty providers . 17Support providers . 17Network facilities . 17Out-of-network providers . 18How much you will pay . 18Network consent for out-of-network services . 20Services received outside the service area . 21Out-of-area services . 22Services received outside the United States . 23What you pay for medical services . 25Deductible . 25Coinsurance . 27Copay . 27When you pay . 28Medical out-of-pocket limit. 28Summary of services and payments . 29Deductible and limits . 30Types of services . 31What else you need to know . 33Benefits: what the plan covers . 34Guidelines for coverage . 34Health Technology Clinical Committee (HTCC) . 34Summary of benefits . 382021 UMP Plus–UW Medicine ACN (SEBB) Certificate of Coverage5
List of benefits. 40Acupuncture . 40Ambulance . 40Applied Behavior Analysis (ABA) Therapy . 41Autism treatment . 42Bariatric surgery . 42Behavioral health . 42Breast health screening tests . 45Care management . 45Chiropractic physician services . 46Dental services. 46Diabetes care supplies . 48Diabetes Control Program . 49Diabetes education . 49Diabetes Prevention Program (DPP) . 49Diagnostic tests, laboratory, and x-rays . 50Dialysis . 50Durable medical equipment (DME), supplies, and prostheses. 51Emergency room . 53End-of-life counseling . 53Family planning services . 53Foot care, maintenance . 55Genetic services . 55Headaches, chronic migraine or chronic tension type . 55Hearing care (diseases and disorders of the ear) . 55Hearing exam and hearing aids. 55Home health care . 57Hospice care . 57Hospital services . 58Knee arthroplasty, total . 59Mammogram and Digital Breast Tomosynthesis (DBT) . 60Massage therapy . 60Mastectomy and breast reconstruction . 61Mental health . 61Naturopathic physician services . 612021 UMP Plus–UW Medicine ACN (SEBB) Certificate of Coverage6
Nurse line . 61Nutrition counseling and therapy . 62Obstetric and newborn care . 62Office visits . 64Orthognathic surgery . 64Pain and joint management, interventional . 64Prescription drugs. 64Preventive care . 64Radiology . 67Second opinions . 67Skilled nursing facility .
Jan 01, 2021 · 2021 UMP Plus–UW Medicine ACN (SEBB) Certificate of Coverage 1 . Directory: medical services . Contact type and description
