For all appeals and complaints, we recommend calling the appropriate Customer Service number first. Many issues can be resolved with a phone call. If not, you can always submit a formal complaint or appeal by phone, fax, e-mail, or mail. If you would like someone else to handle your appeal or complaint on your behalf, see "What Is an Authorized Representative?" below.
Issues involving prescription drugs:
Washington State Rx Services
Issues not involving prescription drugs:
UMP Customer Service
1-888-849-3681 (TTY 711)
For medical appeals and complaints:
Uniform Medical Plan
PO Box 2998
Tacoma, WA 98401-2998
Email: For secure e-mail appeals, use our online appeals form.
For prescription drug appeals and complaints:
Washington State Rx Services
PO Box 40168
Portland, OR 97240-0168
If your plan decides not to pay a claim or pays less than you wanted, you can file an appeal.
Examples of appeal issues are:
In contrast, if your mail-order prescription drug is late or processing of a claim is slower than you'd like, that is a complaint.
Complaints are generally sent directly to whoever can either fix the problem or respond to your concerns. By law, appeals are handled in levels: first, second, and independent review. Different offices and people handle each level. Complaints are not eligible for an independent review.
Your plan will handle your appeal faster if you provide all the following information when you file it:
Because of privacy laws, the plan usually cannot share personal health information (including that related to an appeal or complaint) with family members or other persons unless the patient is a minor, or the plan has received written authorization to release personal health information to the other person.
If you want anyone else to handle your appeal or complaint on your behalf, you must send a completed Authorization to Disclose Protected Health Information (available by calling 1-888-849-3681) to the address on the form before the plan can communicate with the other person. See "How to Designate an Authorized Representative" for instructions.
We will let you know that we've received your appeal within 72 hours. Your plan complies with the Washington State Patient Bill of Rights regarding timelines and most appeals are handled in 30 days or less. Please see the current Certificate of Coverage for your plan for a complete description of the appeals process and your rights.
If we need more information to make a decision, we will contact you and let you know what's needed. If we don't get the needed information, your appeal may be delayed or denied.
An independent review is also known as an external review. These are handled by organizations staffed by legal and health care professionals who specialize in reviewing disputes over health care issues.
Not all appeals qualify for independent review. Please see the appeals section of the current UMP Certificate of Coverage for details on the process.
You must request an independent review within 180 days of the date of the decision. You will receive instructions as to how to request an independent review in the decision letter of the second-level appeal, or may call UMP Customer Service at 1-888-849-3681 for information.
The decision by the independent review organization (IRO) is binding unless other remedies are available under state or federal law. See the current UMP Certificate of Coverage for details on how to pursue litigation against the plan.
If your provider determines that a denial of service could seriously jeopardize your life, health, or ability to regain maximum function, or cause severe pain that could not be adequately managed without the care or treatment you are appealing, ask your provider to request an expedited appeal. The provider must submit all clinically relevant information to your plan by phone or fax to:
Fax: 1-877-663-7526 (Providers only. Please say "Attn: Expedited Appeal" on the fax cover sheet)
Your plan is required to make a decision on an expedited appeal within 72 hours of receiving the appeal.
When the decision to deny coverage is based on your not being eligible or not having paid premiums, send your appeal to the PEBB Appeals Manager at 1-800-351-6827, or see more information on the PEBB website.
If you have a complaint or concern about the quality of care received from a health care provider (such as a complaint related to a provider's conduct or ability to practice medicine safely), please report your complaint to the Department of Health by e-mail at HSQAComplaintIntake@doh.wa.gov, or by calling 360-236-4700. You can also visit the DOH website for more information.
For a complete description of the appeals process and your rights, see the "Complaint and Appeal Procedures" section of the current Certificate of Coverage for your plan.