Complaint and Appeal Procedures

Problems with claims or coverage?

Use our Online Appeal/ Complaint Form

Appeals and Complaints

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.

Customer Service Contact Numbers

Issues involving prescription drugs:
Washington State Rx Services
1-888-361-1611

Issues not involving prescription drugs:
UMP Customer Service
1-888-849-3681 (TTY 711)

Where Do I Send My Complaint or Appeal?

For medical appeals and complaints:
Uniform Medical Plan
PO Box 2998
Tacoma, WA 98401-2998
Fax: 1-877-663-7526
Email:  For secure e-mail appeals, use our online appeals form.

For prescription drug appeals and complaints:
Washington State Rx Services
Attn: Appeals
PO Box 40168
Portland, OR 97240-0168
Fax:  1-866-923-0412

How are Complaints and Appeals Different?

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:

  • You want your plan to pay more for a service.
  • A service was not covered, and you think it should have been.
  • Your request for a service to be preauthorized was denied and you think it should be covered.

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.

What Should I Send With My Appeal?

Your plan will handle your appeal faster if you provide all the following information when you file it:

  • The subscriber's full name (the name of the employee or retiree covered by the plan).
  • The patient's full name (the name of the employee, retiree, or family member covered by the plan).
  • The member's ID number (the one starting with a "W" on the member ID card).
  • The name(s) of any provider(s) involved in the issue you are appealing.
  • The dates when services were provided.
  • Your mailing address.
  • Your daytime phone number(s).
  • A statement of what the issue is and what you are asking for.
  • A copy of the Explanation of Benefits, if applicable.
  • Medical records from your provider, if applicable. For cases in which coverage was denied based on medical necessity or other clinical reasons, your provider should supply clinically relevant information such as a letter of medical necessity, medical records, etc. along with your appeal. Because of the time limits on deciding appeals, getting this information in advance will help us make the most accurate decision on your case.

What Is an Authorized Representative?

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.

What Happens After I Send in My Appeal?

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.

What Is an Independent Review?

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.

Expedited Appeals

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:

Phone: 1-888-849-3681
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.

Appeals Related to Eligibility

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.

Complaints Regarding Provider Conduct or Quality of Care

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.