Complaint and Appeal Procedures

Problems with claims or coverage?

Customer Service Contact Numbers
Where Do I Send My Complaint or Appeal?
How Are Complaints and Appeals Different?
What Should I Send With My Appeal?
What Happens After I Send in My Appeal?
What Is An Independent Review?
Expedited Appeals
Appeals Related to Eligibility
Complaints Regarding Provider Conduct or Quality of Care

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.

Customer Service Contact Numbers

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

For issues not involving prescription drugs:
Uniform Medical Plan
1-800-762-6004

Where Do I Send My Complaint or Appeal?

For prescription drug appeals and complaints:
Washington State Rx Services
Attn: Appeals
PO Box 40168
Portland, OR 97240-0168
Fax: 503-243-5105

For medical appeals and complaints:
Uniform Medical Plan
PO Box 34578
Seattle, WA 98124-1578
Fax: 425-670-3197

Email: For secure e-mail appeals, use our online appeals form.

How Are Complaints and Appeals Different?

Examples of appeal issues are:

You want UMP to pay more for a service.
UMP didn't cover something at all, and you think we should have.
You want something covered that UMP doesn't normally cover.

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?

UMP will handle your appeal more quickly if you provide all the necessary information when you file it. Please include the following information when requesting an appeal:

The subscriber's full name (the name of the employee or retiree covered by UMP).
The patient's full name (the name of the employee, retiree, or family member covered by UMP).
The UMP ID number (the one starting with a "W" on your 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).
Your e-mail address, if you have one.
A statement of what the issue is and what you are asking for.
A copy of the Explanation of Benefits sent by UMP, if applicable.
Medical records from your provider, if applicable. For cases in which UMP denied coverage 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 take better-informed actions on your case.

What Happens After I Send in My Appeal?

We will let you know that we've received your appeal within 5 business days. UMP complies with the Patient Bill of Rights regarding timelines; most appeals are handled within 30 days or sooner. Please see the current UMP Certificate of Coverage 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.

To qualify for an independent review, you must first go through both the first and second levels of appeal. If you are dissatisfied with UMP's decision on the second-level appeal, you must request an independent review within 180 days of the date of UMP's decision. You will receive instructions as to how to request an independent review in the decision letter of the second-level appeal.

The decision by the independent review organization (IRO) is final.

Expedited Appeals

If your provider determines that UMP's denial of services would seriously affect your life, health, or ability to regain maximum function, ask your provider to request an expedited appeal. The provider must submit all clinically relevant information to UMP by phone or fax to:

Phone: 206-521-2000
Fax: 206-521-2001 (please say "Attn: Expedited Appeal" on the fax cover sheet)

UMP is required to make a decision on an expedited appeal within 72 hours of receiving the appeal.

Appeals Related to Eligibility

When UMP's decision to deny coverage is based on your not being eligible or not having paid premiums, send your appeal to:

Phone:
PEBB Benefit Services 1-800-200-1004

Mail:
Health Care Authority
PEBB Appeals Manager
PO Box 42699
Olympia, WA 98504-2699

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 hpqa.csc@doh.wa.gov or 360-236-4700, or visit its Web site (https://fortress.wa.gov/doh/hpqa1/disciplinary/complaint.htm) for more information.

For a complete description of the appeals process and your rights, see the "Complaint and Appeal Procedures" section of the current UMP Certificate of Coverage.