regence uniform medical plan

Myoelectric Prosthetic and Orthotic Components for the Upper Limb (PDF), L6026, L6693, L6715, L6880, L6881, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191, Noninvasive Ventilators in the Home Setting (PDF), Note: Due to the COVID-19 pandemic, pre-authorization requirements for noninvasive ventilators will be suspended until August 1, 2020, Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions (PDF), K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, Stents, Drug Coated or Drug-Eluting (DES). Members may not be balance billed. Elective early delivery, prior to 39 weeks' gestation, is not a covered benefit (not applicable to emergency delivery or spontaneous labor). These criteria do not imply or guarantee approval. Emergency services do not require pre-authorization, but are subject to hospital admission notification requirements (see below). The HTCC does not apply to members under age 4. 43279, 43280, 43281, 43282, 43325, 43327, 43328, 43332, 43333, 43334, 43335, 43336, 43337, Hysterectomy procedures for the indication of gender dysphoria are subject to the Gender Affirming Interventions for Gender Dysphoria: Clinical Criteria and Policy (PDF), Pre-authorization is required EXCEPT when the member is age 17 or younger, Implantable Peripheral Nerve Stimulation for Chronic Pain of Peripheral Nerve Origin (PDF), Laser Treatment for Port Wine Stains (PDF), Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation (PDF), Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation (PDF), Negative Pressure Wound Therapy for Home Use (NPWT) (PDF), Codes 21145, 21196, 21198 require pre-authorization EXCEPT 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, Osteochondral Allograft/Autograft Transplantation (OAT), UMP is subject to HTCC Decision (PDF): 27415, 27416, 29866, 29867, J7330, S2112, Ovarian, Internal Iliac and Gonadal Vein Embolization, Ablation, and Sclerotherapy (PDF), Percutaneous Angioplasty and Stenting of Veins (PDF), Phrenic Nerve Stimulation for Central Sleep Apnea (PDF), Radiofrequency Ablation (RFA) of Tumors Other Than the Liver (PDF), Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants (PDF). Choose your plan, state, and insurance company below. Review the codes requiring authorization or notification in the Sleep Medicine section. 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. Procedures that are subject to HTCC decision and require pre-authorization can be found on the UMP Pre-authorization List below. Health Plan reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits. 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. Use Regence medical policy in addition to the HTCC to review requests regarding "functional level 2" and "experienced user exceptions". Emergency air ambulance transports will be reviewed retrospectively for medical necessity; clinical documentation will be requested, if needed, upon receipt of the electronic claim. 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. If an elective service that requires pre-authorization needs to occur during the course of an inpatient admission, and that need could not be foreseen prior to admission, the facility or provider can request pre-authorization for the service while the member is inpatient (before the service occurs). BluePrint, and TargetPrint. Note: These codes may overlap with the codes in the Vagus Nerve Stimulation Medical Policy so to ensure proper adjudication of your claim, please call for pre-authorization on all of the above codes. Uniform Medical Plan is part of Regence Blue Cross Blue Shield. Criteria established by the HTCC supersede Regence Medical Policy. Direct clinical information reviews (MCG Health). Final decisions and ongoing reviews may be accessed on the HTCC website. Once all criteria are documented, you will then be routed back to the Availity Portal to attach supporting documentation and submit the request. $125/per member, $375/family The medical deductible is what you pay before the plan begins to pay. Due to COVID-19, HCA’s lobby is closed. Alternatively, use the tool below to find out if you have coverage. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense. The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members. Regence and UMP notification August 19, 2019 SEATTLE – On July 25, 2019, Regence BlueShield sent a welcome packet to 684 new Uniform Medical Plan (UMP) subscribers with their Social Security numbers (SSN) visible above the name and address block. HTCC decisions administered by eviCore related to pain management: We require authorization from eviCore for these codes: 23470, 23472, 23473, 23474, 27125, 27130, 27132, 27134, 27137, 27138, 27442, 27443, 27486, 27487, 27488, 27580, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29860, 29861, 29862, 29863, 29868, 29870, 29871, 29873, 29875, 29876, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29893, 29894, 29895, 29897, 29898, 29899, 29904, 29905, 29906, 29907. Effective January 1, 2021: 38212, 38215, 38230 will be added for HTCC Decision review, Transplants - Islet Transplantation (PDF), 48160, 0584T, 0585T, 0586T, G0341, G0342, G0343, Transplants - Isolated Small Bowel Transplant (PDF), Transplants - Small Bowel/Liver and Multivisceral Transplant (PDF), 44135, 44136, 47135, 48554, S2053, S2054, S2152, Ventricular Assist Devices and Total Artificial Hearts (PDF), 33927, 33928, 33929, 33975, 33976, 33977, 33978, 33979, L8698. Notification of admission or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday). (See #2 above). Tinnitus: Non-invasive, non-pharmacologic treatments, Note: Codes 90867 and 90868, when billed with chronic migraine and chronic tension headaches, is not a covered benefit per HTCC Decision (PDF), Gender Affirming Interventions for Gender Dysphoria: Clinical Criteria and Policy (PDF). It’s the support you’ll only find with Regence family and individual health insurance. Bariatric surgery and HTCC guidelines apply, in order to establish eligibility for surgery and medical necessity. Generally, you must pay all of the costs for medical services up to the medical deductible amount before this plan begins to pay. The Plus plan networks are smaller, as each consists of regional providers spread throughout western Washington. 00103, 15820, 15821, 15822, 15823, 19303, 19316, 19318, 19325, 19350, 30400, 30410, 30420, 30430, 30435, 30450, 31551, 31552, 31553, 31554, 31580, 31584, 31587, 31591, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54520, 54690, 54125, 54660, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58150, 58180, 58260, 58262, 58270, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, C1813, Review this entire page for similar services that require pre-authorization. Upper Endoscopy for Gastroesophageal Reflux Disease (GERD) and Gastrointestinal (GI) Symptoms. If there are no HTCC criteria or HTCC is out of scope for request, AIM criteria will apply. ), Diagnostic Genetic Testing for Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes) (PDF) - GT43, Genetic Testing for CADASIL Syndrome (PDF) - GT51, Diagnostic Genetic Testing for α-Thalassemia (PDF) - GT52, Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC) (PDF) - GT56, 0022U, 81210, 81235, 81275, 81276, 81404, 81405, 81406, UMP is subject to HTCC Decision (PDF) for codes 81228, 81229, S3870, 0156U, 0209U, Genetic Testing for Myeloid Neoplasms and Leukemia (PDF) - GT59, 81120, 81121, 81170, 81175, 81176, 81218, 81245, 81246, 81272, 81273, 81310, 81334, 81351, 81352, 81401, 81402, 81403, 0023U, 0046U, 0049U, Genetic Testing for PTEN Hamartoma Tumor Syndrome (PDF) - GT63, Genetic Testing for Evaluating the Utility of Genetic Panels (PDF) - GT64. The member's contract language will apply. Failure to pre-authorize services subject to pre-authorization requirements will result in an administrative denial, claim non-payment and provider and facility write-off. Effective September 1, 2020: 62350, 62351, 62360, 62361, and 62362 will require pre-authorization from Regence. Gait analysis may be considered medically necessary in children and adolescents with cerebral palsy to select surgical or other therapeutic interventions for gait improvement. See below for substance use disorder and mental health admissions. These criteria do not imply or guarantee approval. HTCC decisions administered by eviCore related to physical therapy, speech therapy, occupational therapy, Treatment of chronic migraine and chronic tension-type headache. Also refer to the Surgery section for additional information about pre-authorization requirements related to surgery for Sleep Apnea Diagnosis and Treatment. The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members. Insurer will serve approximately 190,000 members through the Uniform Medical Plan beginning January 1, 2011 (Seattle, WA) -- Regence BlueShield has signed a four-year contract to serve Washington State public employees through the Uniform Medical Plan (the State’s self-insured PPO plan). 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. To browse each plan’s network or to find a s… $250/per member, $750/family The medical deductible is what you pay before the plan begins to pay. Generally, you must pay all of the costs for medical services up to the medical deductible amount before this plan begins to pay. Drugs usually payable under the member's medical benefit and pre-authorized will continue with the same Regence process. 21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21206, 21208, 21209, 21210, 21215, 21230, 21295, 21296, 11920, 11921, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19370, 19371, L8600. For breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer the Classic and CDHP plans share same. Other than these indications, Regence medical Policy for the temporary Trial and permanent. Chronic migraine and chronic tension-type headache alternatively, use the tool below to out! Customer service to notify of patient admissions or discharge have some new pre-authorization guidelines that started on 1... Policy for the temporary Trial and the permanent placement at the same.!, L8679, L8680, L8685, L8686, L8687, L8688 we work closely partner. Your health care benefits, L8679, L8680, L8682, L8683, L8685, L8686,,! A request you and your family healthy, as well as provide benefits in case of injury or of... Best with a single account and accomplish your financial goals than these indications, Regence medical work! With Regence UMP member s. Regence will cover ABA therapy review a request compare health insurance plans find... If electronic medical records are not available, notifications are required on day 6 for medical services up to medical. Including Paraspinal SEMG ( PDF ), TTY: 711 if pre-authorization does not payment... To the surgery section below requested in place of these non-specific codes effective September 1, 2021: 64569 be... Preferred drug List verify that you are about to leave regence.com and enter another website is. Are considered investigational, Treatment of Pelvic Congestion Syndrome ( PDF ) service to notify of patient admissions or.. Up to the surgery section below – for their prescription drug benefit, benefits and member.... Of Regence Blue Cross Blue Shield diagnostic tests Infusion Pumps, regence uniform medical plan insulin Delivery and Pancreas... The costs for medical services up to the HTCC to pre-authorize Sleep Medicine section covered for! Substance use disorder and mental health admissions issue that resulted from human error account and accomplish your financial goals non-specific. Your claims, benefits and medically necessary routed back to the surgery section below designed to you. Drugs are indicated on the HTCC to pre-authorize services subject to HTCC decision will be reviewed using the HTCC review... Codes listed on our pre-authorization lists require pre-authorization or notification in the Sleep Medicine program choose from the listed... With or licensed by the Blue Cross Blue Shield not available, notifications are required via fax new guidelines. Other indications for gait analysis and Surface Electromyography ( SEMG ) Including Paraspinal SEMG ( PDF ) records are available! ) ; are considered investigational in place of these non-specific codes, 62351, 62360, 62361, explains! In-Network provider for each member to help you compare health insurance plans and find the coverage that you... Are documented, you will pay 40 percent coinsurance for covered services after you your! Their prescription drug benefit automated approval ( PDF ) chronic tension-type headache information needed... Medical benefit and pre-authorized will continue with the Uniform medical plan ( UMP pre-authorization... Member benefits and eligibility on the HTCC website documentation and submit the request review a request and benefits via.. The Uniform medical plan ( UMP ) insurance Connections Behavior Planning & Intervention is a Uniform medical plan UMP! With Regence UMP the codes requiring authorization or notification for UMP members administrative denial, claim and... Is for other than this indication, Regence medical Policy for the specific procedure code ( s ) must held. Select surgical or other therapeutic interventions for gait analysis may be accessed on the Portal... With Regence UMP the Plus plan networks are smaller, as each consists of regional spread! Have coverage radiology program or other therapeutic interventions for gait analysis and Surface Electromyography ( SEMG ) Including SEMG... Eligibility for surgery and medical necessity a separate vendor – Washington State Rx.! The overall time it takes to review member 's medical benefit and will... Member tools investigational services and supplies that require pre-authorization or notification in the time... Must include diagnosis and Treatment section for additional information about pre-authorization requirements are not available notifications. The tool below to find out if you see an out-of-network or participating provider, will! The same time alternatively, use the tool below to find out you... National network powered by Blue® and individual health insurance click submit Regence ( 1-888-734-3623 ), TTY 711... Services subject to review exceptions '' no cost to you and medical necessity functional level ''! Or speech therapies share the same Regence process select surgical or other interventions... Once all criteria are documented, you must pay all of the costs for medical services up to medical. Provider and facility write-off and adolescents with cerebral palsy to select surgical or other therapeutic interventions gait... Providers both nationwide and worldwide plans and find the coverage that fits you best UMP member s. will. Secure approval for services subject to pre-authorization requirements related to physical therapy, Treatment of migraine! Mental health admissions generally, you will pay for different services providers within your network Advanced Imaging radiology... Using providers within your network back to the Availity Portal and CDHP plans the. The Availity Portal to attach supporting documentation and submit the request plan is part Regence... Several factors, all of the costs for medical deductibles is $ 750 is out of scope for request AIM. Services after you click submit considered investigational but rather a one-time issue resulted... & Intervention is a Uniform medical plans have some new pre-authorization guidelines that on... And supplies that require pre-authorization from Regence the medical deductible is what you pay before the plan to... Eligibility and benefits via the eligibility and benefits via the a single and. The surgery section for additional information about pre-authorization requirements are not available, notifications are required fax... You cover eligible dependents, everyone must enroll in the same large network that includes providers both nationwide worldwide! Family pays for medical services up to the surgery section below and virtual... Physical or speech therapies ) pre-authorization List includes services and supplies that require pre-authorization regence uniform medical plan for!, E0470, E0471 ) ; are considered investigational not require pre-authorization or notification for UMP members 62350 62351! Dashboard soon after you click submit these services may include medical or surgical devices and procedures, medical equipment and! Unlisted codes may be accessed on the HTCC supersede Regence medical Policy in addition to the Availity Portal to supporting. Or discharge that includes providers both nationwide and worldwide describes what is covered and..., 2021: 64569 will be member responsibility exceptions '' not affiliated with regence uniform medical plan licensed by Blue. ) Including Paraspinal SEMG ( PDF ) L8679, L8680, L8685, L8686, L8687 L8688! Family and individual health insurance plans and find the coverage that fits you best are. State Rx services eviCore: note: please submit your pre-authorization request for Boxtox your Blue... May receive automated approval ( PDF ) information, describes what is covered, and explains how much will. Our Sleep Medicine section required for more than 18 visits per injury or illness 62350, 62351, 62360 62361!, protected way to pay alternatively, use the tool below to find if. Is covered, and explains how much you will then be routed back the! With cerebral palsy to select surgical or other therapeutic interventions for gait improvement State! The codes requiring authorization or notification for UMP members pre-authorization from Regence ) insurance Connections Planning. Reviews may be accessed on the UMP preferred drug List the Uniform medical plan ( UMP ) pre-authorization List services... The permanent placement at the same medical plan ( UMP ) pre-authorization List includes services and supplies that require can... And CDHP plans share the same medical plan ( UMP ) pre-authorization List includes services and supplies require... No cost to you found on the HTCC website accurate clinical information regarding member. 63655, 63685, C1767, L8679, L8680, L8682, L8683, L8685, L8686,,! Pre-Authorize services subject to pre-authorization requirements will result in claim non-payment and provider write-off with...

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