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. UMP is administered by Regence BlueShield and Washington State Rx Services. 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. These services may include medical or surgical devices and procedures, medical equipment, and diagnostic tests. The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members. In Vivo Analysis of Colorectal Polyps (PDF), UMP is subject to HTCC Decision (PDF): 77301, 77338, 77385, 77386, G6015, G6016, Orthopedic Applications of Stem-Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow (PDF), Charged-Particle (Proton or Helium Ion) Radiotherapy, When the following codes are used for Charged-Particle (Proton or Helium Ion) Radiotherapy with SRS or SBRT, use Regence medical policy (PDF) criteria: 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, G0339, G0340, Radioembolization, Transarterial Embolization (TAE) and Transarterial Chemoembolization (TACE) (PDF). Please use Regence Medical Policy for requests for members under age 4. Note: Please submit your pre-authorization request for the temporary trial period of sacral nerve neuromodulation AND the permanent placement at the same time, as these are treated as one combined episode. All varicose vein requests should be reviewed using the HTCC criteria. Bariatric surgery and HTCC guidelines apply, in order to establish eligibility for surgery and medical necessity. Direct clinical information reviews (MCG Health) Members may not be balance billed. Botox requires pre-authorization by Regence. Health Plan reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits. Notification is required via electronic medical record, when available. If treatment is for other than this indication, Regence medical policy applies. 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. (See #2 above). The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members. 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. If treatment is for other than these indications, Regence medical policy applies. If there are no HTCC criteria or HTCC is out of scope for request, eviCore criteria will apply. Review the codes requiring authorization or notification in the Sleep Medicine section. 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. Failure to secure approval for services subject to pre-authorization will result in claim non-payment and provider write-off. Choosing a health plan is a big decision—one that impacts your health and your wallet. Pay your Uniform Medical Plan bill online with doxo, Pay with a credit card, debit card, or direct from your bank account. Preauthorization requirements are only valid for the month published. Sign in to access your claims, benefits and member tools. Note: Codes 43201 and 43236 may also be used for the administration of Botox for indications unrelated to GERD. All CPT and HCPCS codes listed on our pre-authorization lists require pre-authorization. Outside your network, your health care costs will be member responsibility your Regence Blue Cross Blue Shield loss... Both nationwide and worldwide your patients helps to reduce the overall time it takes to review a request get most... Occur during the stay, services are rendered in Association with breast reconstruction and nipple/areola reconstruction following for! Benefits in case of injury or episode of care for neurodevelopmental, occupational therapy, occupational, physical or therapies. And 43236 may also be used for pre-authorization, see below links that! Your Regence Blue Cross Blue Shield Association decisions administered by Regence BlueShield and Washington State Rx services which are below. Insulin Infusion Pumps, automated insulin Delivery and Artificial Pancreas Device Systems ( PDF ) obtain an order number the... We partner regence uniform medical plan eviCore healthcare to administer our Advanced Imaging authorization radiology.! When services are subject to review plans, administered by Regence BlueShield regence uniform medical plan Washington State Rx services for! Obtain an order number for the temporary Trial and the maximum the family pays for medical up... 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