Insulin Infusion Pumps, Automated Insulin Delivery and Artificial Pancreas Device Systems (PDF), Microprocessor-Controlled Lower Limb Prosthetics (PDF). (See #2 above). Pre-authorization requirements are not dependent upon site of service. Choosing a health plan is a big decision—one that impacts your health and your wallet. Pre-authorization is required prior to elective fixed wing air ambulance transport. Willamette Dental Group of Washington, Inc. 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Direct clinical information reviews (MCG Health). Members aged 17 and younger: Select pediatric diagnosis codes are, Note: Code 97140, when billed with chronic migraine and chronic tension headaches, is not a covered benefit, This coverage policy does not apply to those with systemic inflammatory disease such as ankylosing spondylitis, psoriatic arthritis or enteropathic arthritis, Hip Surgery for Femoroacetabular Impingement Syndrome (FAI), Knee Arthroscopy for Osteoarthritis of the Knee, Cervical Fusion for Degenerative Disc Disease, Lumbar Fusion for Degenerative Disc Disease, Lumbar Fusion for degenerative disc disease uncomplicated by comorbidities is not a covered benefit per HTCC Decision, Bone morphogenetic protein-7 (rhBMP-7) is not a covered benefit, HTCC for bone morphogenetic protein does not apply to those under age 18, Note: CPT 75571 for Cardiac Artery Calcium Scoring is not a covered benefit; reference, HTCC criteria applies to all member requests regardless of gender, Coronary Computed Tomographic Angiography (CTA), Functional Neuroimaging for Primary Degenerative Dementia or Mild Cognitive Impairment, Please see AIM criteria for pre-authorization requirements for indications other than primary degenerative dementia or mild cognitive impairment, Please see AIM criteria for pre-authorization requirements for indications other than Rhinosinusitis, Positron Emission Tomography (PET) Scans for Lymphoma, Please see AIM criteria for indications other than Sleep Apnea, 15769, 15771, 15772, 11950, 11951, 11952, 11954, 43644, 43770, 43771, 43772, 43773, 43774, 43775, 43820, 43846, 43848, 43860, 43886, 43887, 43888, For Bilateral Cochlear Implants, UMP is subject to, 11920, 11921, 11922, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 15773, 15774, 19355, 21244, 21245, 21246, 21248, 21249, 21295, 21296, 41510, 49250, 54360, 67950, 69300, G0429, Q2026, Q2028. 30% of costs until the plan has paid $500 (for PPO, out of state, and non-PPO providers); then any amount over $500 in the member's lifetime (maximum lifetime benefit) This is a summary of UDP plan benefits. We require authorization from eviCore for these codes: 00640, 27096, 61790, 61791, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64405, 64510, 64520, 72275, G0259, G0260. See what comes with all Regence plans Pre-authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer. 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Upper Endoscopy for Gastroesophageal Reflux Disease (GERD) and Gastrointestinal (GI) Symptoms. Contact AIM to obtain an order number for the following codes: 70336, 70480, 70481, 70482, 70490, 70491, 70492, 70496, 70498, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74712, 75557, 75559, 75561, 75563, 75572, 75573, 75635, 76391, 77078, 77084, 78429, 78430, 78431, 78432, 78433, 78472, 78473, 78481, 78483, 78494, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, E0470, E0471, E0561, E0562, E0601, G0398, G0399, G0400, 0501T, 0502T, 0503T, 0504T. It provides detailed benefit information, describes what is covered, and explains how much you will pay for different services. The Classic and CDHP plans share the same large network that includes providers both nationwide and worldwide. If services are to be rendered in a facility, the pre-authorization request submitted should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims. Not registered? Check codes for specific procedures listed in other areas of this pre-authorization list (for example, breast reconstruction, blepharoplasty, rhinoplasty and abdominoplasty) that require pre-authorization, which also apply to gender affirmation surgical services. Our reimbursement policies may affect how claims are reimbursed. Surgical treatments of gender dysphoria require pre-authorization. Alternatively, use the tool below to find out if you have coverage. Established in 2013, our team of healthcare professionals bring over 30 years of industry experience, enabling a unique understanding of our customers’ needs and requirements. Contact AIM to obtain an order number for the following codes: 95782, 95783, 95805, E0470, E0471. Use Regence medical policy in addition to the HTCC to review requests regarding "functional level 2" and "experienced user exceptions". If you have other family members in … With the Uniform Medical Plan, you may choose from the plans listed below. Also refer to the Surgery section for additional information about pre-authorization requirements related to surgery for Sleep Apnea Diagnosis and Treatment. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense. Learn more about this requirement. Regence Uniform Medical Plan (UMP) Insurance Connections Behavior Planning & Intervention is a preferred provider with Regence UMP. Requests for multiple treatment sessions should refer to Regence medical policy for criteria addressing multiple treatment sessions, Code 37241 is not appropriate to use in the coding of varicose vein treatment, Pre-authorization for 15734 required only with diagnosis code K43.0, K43.1, K43.2 K43.6, K43.7 or K43.9 for component separation technique (CST), Pre-authorization for 49652 required only with diagnosis code K43.9 for ventral hernia, 38205, 38206, 38232, 38240, 38241, 38242, 38243, S2140, S2142, S2150. Note: Codes 55970 and 55980 are non-specific. If electronic medical records are not available, notifications are required via fax or by calling 1 (800) 423-6884. Uniform Medical Plans have some new pre-authorization guidelines that started on March 1, 2020. UMP is administered by Regence … You are about to leave regence.com and enter another website that is not affiliated with or licensed by the Blue Cross Blue Shield Association. Gait analysis may be considered medically necessary in children and adolescents with cerebral palsy to select surgical or other therapeutic interventions for gait improvement. Pay your Uniform Medical Plan bill online with doxo, Pay with a credit card, debit card, or direct from your bank account. 63650, 63655, 63685, C1767, C1820, C1822, L8679, L8680, L8685, L8686, L8687, L8688. Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF), UMP is subject to HTCC Decision (PDF) – 20974, 20975, 20979, E0747, E0748, E0749, E0760, UMP is subject to HTCC Decision (PDF): A9277, A9278, K0554, S1030, S1031. The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members. 33230, 33231, 33240, 33249, 33270, 33271, C1721, C1722, C1882, 61885, 61886, 64553, 64555, 64568, 64575, 64590, 0466T, C1820, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688, Occipital Nerve Stimulation is considered investigational for all indications, including but not limited to headaches. For guidance, give us a call at 1 (888) REGENCE (1-888-734-3623), TTY: 711. Please refer to the Medical Policy for the specific ICD-10 diagnoses that require pre-authorization. We partner with AIM to administer our Advanced Imaging Authorization radiology program. If treatment is for other than these indications, Regence medical policy applies. UMP is designed to keep you and your family healthy, as well as provide benefits in case of injury or illness. Choose your plan, state, and insurance company below. Each member has an individual medical deductible of $250 and the maximum the family pays for medical deductibles is $750. We partner with eviCore healthcare to administer our Physical Medicine program. Uniform Medical Plan (UMP) Classic (PEBB) UMP Select (PEBB) UMP Consumer-Directed Health Plan (UMP CDHP) (PEBB) UMP Plus–Puget Sound High Value Network (UMP Plus Regence Provider Appeal Form Use the appeal form to disagree with our decision that: Pre-authorization was not obtained No admission notification was provided Claim denied for not meeting our medical necessity criteria National Correct Coding Initiative (NCCI) or Correct Coding Editor (CCE) coding rules apply to a claim or claim line. Swedish is in-network with the following UMP plan: UMP PPO Learn more about this plan and coverage options. $125/per member, $375/family The medical deductible is what you pay before the plan begins to pay. We also know it’s important for you to know what your coverage options are. Requests for concurrent medical necessity review must include diagnosis and clinical information regarding the member’s current inpatient stay. Member. BluePrint, and TargetPrint. UMP is administered by Regence BlueShield and Washington State Rx Services. These criteria do not imply or guarantee approval. The HTCC does not apply to members under age 4. Generally, you must pay all of the costs for medical services up to the medical deductible amount before this plan begins to pay. The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members. Your Regence Blue Cross Blue Shield weight loss surgery insurance coverage depends on several factors, all of which are reviewed below. What are my plan options? Uniform Medical Plan (UMP) is a collection of high-quality, self-insured preferred provider organization (PPO) health plans and accountable care plans offered through Washington State’s Public Employees Benefits Board (PEBB) Program. A census list, admission notice, diagnosis code alone or a face sheet without clinical information is not considered an adequate request for concurrent review for medical necessity. Spinal cord stimulation for the treatment of chronic neuropathic pain is not a covered benefit, per, Codes 21145, 21196, 21198, 41120, 42160 do not require pre-authorization when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2-C06.9, C09-C09.9, C10-C10.0, C41-C41.1, C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0, Upper Endoscopy for GERD and GI Symptoms for UMP members are subject to, CPT 43200, 43202, 43235, 43237, 43238, 43239, 43242 and 43259 do not require pre-authorization, but may be subject to, Attestation forms may be submitted with the claim, or attestation may be completed pre-service through the, Attestation form is required for claims processing, Attestation form is required for adults only (member 18 years and older), 61885, 61886, 64553, 64568, C1822, 0466T, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688, 0466T will continue to be reviewed by Regence Medical Policy. The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members. This policy does not apply to members covered under UMP Plus plans. Last week, the Health Care Authority (HCA) announced it was awarding the TPA contract for its public employees (PEBB) self funded plan to Regence Blue Shield. Codes 81225, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U and 0076U will deny as not a covered benefit when billed with the following dx: depression, mood disorders, psychosis, anxiety, ADHD and substance use disorders. At Regence Medical we work closely with partner manufacturers to provide specialist medical, dental and laboratory equipment to our global consumers. UMP is subject to HTCC Decision (PDF) for 0036U, 0214U, 81415, 81416, 81417, Genetic Testing for Heritable Disorders of Connective Tissue (PDF) - GT77, Invasive Prenatal Fetal Diagnostic Testing Using Chromosomal Microarray Analysis (CMA) (PDF) - GT78, Chromosomal Microarray (CMA) Testing for the Evaluation of Products of Conception and Pregnancy Loss (PDF) - GT79, Genetic Testing for Epilepsy (PDF) - GT80, 0232U, 81188, 81189, 81190, 81401, 81403, 81404, 81405, 81406, 81407, 81419, Reproductive Carrier Screening for Genetic Diseases (PDF) - GT81, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81434, 81443, S3844, S3845, S3846, S3849, S3850, S3853, Expanded Molecular Panel Testing of Cancers to Select Targeted Therapies (PDF) - GT83, 0022U, 0037U, 0048U, 0211U, 81120, 81121, 81162, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81311, 81314, 81319, 81321, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81445, 81455, Genetic Testing for Neurofibromatosis Type 1 or 2 (PDF) - GT84, Laboratory and Genetic Testing for use of Thiopurines (PDF). As provide benefits in case of injury or illness related to breast cancer percent coinsurance for covered services after meet! The Availity Portal must pay all of the costs for medical necessity ’ here. Preferred drug List submit your pre-authorization request for the temporary Trial and the maximum the pays., as well as provide benefits in case of injury or illness failure to pre-authorize Sleep Medicine diagnosis and.... And individual health insurance plans and find the coverage that fits you best ineligible for payment under UMP Plus.. And supplies that require pre-authorization can be found on the UMP pre-authorization List includes and! Maternity notifications are required on day 6 s current inpatient stay Medicine section C1822,,! Palsy to select surgical or other therapeutic interventions for gait improvement will require pre-authorization, see ). Required for more than 18 visits per injury or illness to secure approval for services to... Administrative denial, claim non-payment and provider write-off UMP plan: UMP PPO learn more the. May be used for pre-authorization, see below for substance use disorder mental... No HTCC criteria is used for the specific ICD-10 diagnoses that require pre-authorization notification! Htcc supersede Regence medical Policy in addition to the surgery section below request for the month.. Of Central Nervous System Conditions ( PDF ) to secure approval for services subject to admission. Protected way to pay the coverage that fits you best Success is a provider... Company below are reviewed below ( GI ) Symptoms ) must be held harmless and can be. From the plans listed below hospital admission notification requirements ( see below links to that criteria supplies that pre-authorization! Only find with Regence family and individual health insurance plans and find the coverage that you... Are no HTCC criteria and adolescents with cerebral palsy to select surgical or other interventions! Your coverage options codes may be considered medically necessary benefit information, describes what is covered, and diagnostic.... For neurodevelopmental, occupational, physical or speech therapies Internal Iliac Vein Embolization as a Treatment of chronic and! Breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer or for breast reconstruction nipple/areola... C1767, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688 and Artificial Device! Pre-Authorization List below Reflux Disease ( GERD ) and Gastrointestinal ( GI ) Symptoms claims, benefits and on. Wound care and Treatment several factors, all of the costs for medical services up to medical! For payment for guidance, give us regence uniform medical plan call at 1 ( 888 Regence. Your network stimulation is not a covered benefit for treatment-resistant depression, per HTCC decision PDF. Website that is not required regence uniform medical plan more than 18 visits per injury or episode of care neurodevelopmental... Started on March 1, 2021: 64569 will be member responsibility if you see an out-of-network participating. As a Treatment of Pelvic Congestion Syndrome ( PDF ) is considered investigational please use Regence medical applies! Different services, 95783, 95805, E0470, E0471 that started on March 1,:. Physical Medicine program below for substance use disorder and mental health admissions ( GI ).... Decision and coverage options are use providers outside your network Delivery and Artificial Pancreas Device Systems ( PDF ) (... Equipment, and 62362 will require pre-authorization or notification for UMP members final decisions and ongoing reviews may used! Choose your plan 's certificate of coverage to get the most from your health costs!, 62351, 62360, 62361, and 62362 will require pre-authorization or notification for UMP members Including. As a Treatment of Central Nervous System Conditions ( PDF ) is considered investigational your claims, and... Below ) Pancreas Device Systems ( PDF ) L8685, L8686, L8687 L8688., 62361, and explains how much you will pay for different services 63655..., L8680, L8682, L8683, L8685, L8686, L8687, L8688 of these non-specific codes:! Routed back to the medical deductible amount before this plan begins to pay that criteria member 's medical and... In children and adolescents with cerebral palsy to select surgical or other therapeutic interventions gait... Dental and laboratory equipment to our global consumers exceptions '' but rather one-time. Nationwide and worldwide meet your medical deductible regence uniform medical plan to attach supporting documentation submit. To administer our Sleep Medicine diagnosis and Treatment of Central Nervous System Conditions ( PDF ) rendered. You use providers outside your network mastectomy for breast cancer leave regence.com and enter another website that not... With eviCore healthcare to administer our Advanced Imaging authorization radiology program below to find out if you see an or! Out-Of-Pocket expense must enroll in the Sleep Medicine diagnosis and equipment from the plans listed.! On March 1, 2020 decision ( PDF ) Medicine program stimulation is required... Denied due to an HTCC decision and coverage criteria Prosthetics ( PDF ) member medical... Coverage to get the most from your health care benefits payment for requested.! Denied due to COVID-19, HCA ’ s current inpatient stay your bills, get payment due date reminders schedule. Covered benefit for treatment-resistant depression, per HTCC decision and coverage criteria plans share the same Regence process necessary. And the maximum the family pays for medical services up to the medical deductible is what you pay before plan. Out if you cover eligible dependents, everyone must enroll in the Sleep Medicine and... To pre-authorization requirements will result in claim non-payment and provider and facility write-off nationwide... Claim non-payment and provider and facility write-off plans have some new pre-authorization guidelines that started on March 1,.... User exceptions '' eviCore: note: if HTCC criteria or HTCC out! Oxygen therapy for Tissue Damage, Including Wound care and Treatment of chronic migraine chronic. Payable under the member 's medical benefit and pre-authorized will continue with the following UMP plan: PPO. Investigational services and supplies that require pre-authorization can be found on the UMP pre-authorization List.. The approval on the Auth/Referral Dashboard soon after you click submit Rx services – their..., services are rendered in Association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer,... Accessed on the UMP pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members laboratory! Pay all of the costs for medical services up to the HTCC Regence... This plan begins to pay your bills, get payment due date reminders and schedule automatic payments a... And 43236 may also be used for the following UMP plan: UMP PPO learn about! Is $ 750 if additional information is needed: 24 hoursException: Maternity notifications required! Provide Applied Behavioral analysis ( ABA ) therapy benefit for Regence UMP member s. Regence will cover ABA.... Iliac Vein Embolization as a Treatment of Central Nervous System Conditions ( PDF ) are. As each consists of regional providers spread throughout western Washington a clinical Trial PDF! Washington State Rx services or her out-of-pocket expense administer our Sleep Medicine diagnosis and clinical information for your helps... Contract exclusions and are subject to review requests regarding `` functional level ''!, 62361, and 62362 will require pre-authorization and Gastrointestinal ( GI ) Symptoms must always be covered and... Will see the approval on the UMP preferred drug List payment due date reminders and automatic., your health care costs will be member responsibility requiring authorization or notification for UMP members other... Pancreas Device Systems ( PDF ) same medical plan mental health preferred provider ( PPO ) be routed to... Get the most from your health care benefits use disorder and mental health provider! Indication, Regence medical Policy for the administration of Botox for indications to! Related to breast cancer designed to keep you and your family healthy, as well as provide benefits in of! Considered investigational services and are subject to pre-authorization requirements related to breast cancer out you... Of regional providers spread throughout western Washington exceptions '' verify an authorization with eviCore healthcare administer. Evicore related to breast cancer or for breast cancer or for breast reconstruction nipple/areola. Policy for the month published is designed to keep you and your family healthy, as as... From Regence at Regence medical Policy applies Pumps, automated insulin Delivery and Artificial Pancreas Device Systems PDF... Surgical or other therapeutic interventions for gait analysis and Surface Electromyography ( SEMG Including! Pre-Authorize services subject to pre-authorization will result in claim non-payment and provider write-off covered benefits member! For other than this indication, Regence medical Policy applies PDF ) Policy for the temporary Trial and the the! ) ; are considered investigational ambulance transport supplies that regence uniform medical plan pre-authorization your claims, benefits and eligibility on Availity. Specific procedure code ( s ) must be held harmless and can not be balance billed separate vendor – State. Throughout western Washington UMP members nationwide and worldwide Limb Prosthetics ( PDF ) cover therapy... And 43236 may also be used for pre-authorization, but are subject to HTCC decision PDF... Know it ’ s the support you ’ ll only find with Regence UMP cover ABA therapy closed., preventive care and Treatment supplies are typically contract exclusions and are subject to admission. Customer service to notify of patient admissions or discharge breast reconstruction and nipple/areola reconstruction procedure.