Unlisted codes may be used for potentially investigational services and are subject to review. 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). Upper Endoscopy for Gastroesophageal Reflux Disease (GERD) and Gastrointestinal (GI) Symptoms. Learn more about your customer service options. Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair (PDF), 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950, Pre-authorization is not required for members being treated for a condition other than stable angina, UMP is subject to HTCC Decision (PDF): 37215, 37216, 37217, 37246, 37247, Catheter Ablation Procedures for Supraventricular Tachyarrhythmias (SVTA), UMP is subject to HTCC Decision (PDF): 93653, 93655, 93656, 93657, Cosmetic and Reconstructive Surgery (PDF), Cryosurgical Ablation of Miscellaneous Solid Organ, Pulmonary, and Breast Tumors (PDF), Effective March 1, 2021: Policy title will be changed to "Cryosurgical Ablation of Micellaneous Solid Tumors Outside of the Liver". Our reimbursement policies may affect how claims are reimbursed. $125/per member, $375/family The medical deductible is what you pay before the plan begins to pay. Members may not be balance billed. Obtain or verify an authorization with eviCore: Note: If HTCC criteria is used for pre-authorization, see below links to that criteria. 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. It’s the support you’ll only find with Regence family and individual health insurance. At Regence Medical we work closely with partner manufacturers to provide specialist medical, dental and laboratory equipment to our global consumers. 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. Bariatric surgery and HTCC guidelines apply, in order to establish eligibility for surgery and medical necessity. Pre-authorization is only required for diagnoses related to abnormal uterine bleeding, pelvic pain (including pain related to endometriosis, Essure placement, prior endometrial ablation, and vaginal agenesis), chronic pelvic inflammatory disease, pelvic adhesive disease, pelvic venous congestion, adenomyosis, cervical intraepithelial neoplasia, and leiomyoma. Pre-authorization is required for elective inpatient admissions. If pre-authorization does not occur during the stay, services are subject to review post-service for medical necessity. Pre-authorization is required prior to elective fixed wing air ambulance transport. Hyperbaric Oxygen Therapy for Tissue Damage, Including Wound Care and Treatment of Central Nervous System Conditions (PDF). Live your best with a Regence health plan Head-to-toe coverage and low-cost virtual care. Genetic Testing for Alzheimer's Disease (PDF) - GT01, Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome (PDF) - GT02, 0235U, 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81307, 81308, 81321, 81322, 81323, 81404, 81405, 81406, 81432, 81433, 81351, 81352, Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease (PDF) - GT05, Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes (PDF) - GT06, 0238U, 81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81406, Genetic Testing for Cutaneous Malignant Melanoma (PDF) - GT08, Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing (PDF) - GT10. See Regence medical policy Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome (PDF), Temporomandibular Joint (TMJ) Surgical Interventions, Transcutaneous Bone Conduction and Bone-Anchored Hearing Aids (PDF), 69714, 69710, 69715, 69717, 69718, L8690, L8691, L8692, L8694, Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) (PDF). These criteria do not imply or guarantee approval. For guidance, give us a call at 1 (888) REGENCE (1-888-734-3623), TTY: 711. Willamette Dental Group of Washington, Inc. 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We therefore strongly suggest that facilities develop a method to ensure that required pre-authorization requests have been submitted by the physician or other health care professional and approved prior to admission of the patient. (See #2 above). 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. This was not a security breach, but rather a one-time issue that resulted from human error. HTCC decisions administered by eviCore related to joint management: We require authorization from eviCore for these codes: 20931, 20937, 20938, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22325, 22326, 22327, 22328, 22532, 22534, 22548, 22556, 22585, 22590, 22595, 22600, 22610, 22614, 22632, , 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22855, 62380, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63040, 63043, 63045, 63046, 63050, 63051, 63055, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, S2350, S2351. Botox requires pre-authorization by Regence. Pre-authorization is necessary for certain injectable drugs that are not normally approved for self-administration when obtained through a retail pharmacy, a network mail-order pharmacy, or a network specialty pharmacy. Notification is required via electronic medical record, when available. View the services that may receive automated approval (PDF). Direct clinical information reviews (MCG Health). UMP has a separate vendor – Washington State Rx Services – for their prescription drug benefit. Gait analysis may be considered medically necessary in children and adolescents with cerebral palsy to select surgical or other therapeutic interventions for gait improvement. Deep brain stimulation is not a covered benefit for treatment-resistant depression, per HTCC Decision (PDF). Review the codes requiring authorization or notification in the Sleep Medicine section. Members. Services must always be covered benefits and medically necessary. If the physician or other health care professional follows the pre-authorization requirements outlined on our pre-authorization lists, they will not be subject to any pre-authorization penalties for failure of the facility to provide the required inpatient admission and discharge notification. We provide Applied Behavioral Analysis (ABA) therapy benefit for Regence UMP member s. Regence will cover ABA Therapy. The medical deductible is what you pay before the plan begins to pay. All CPT and HCPCS codes listed on our pre-authorization lists require pre-authorization. Uniform Medical Plan (UMP) is a self-funded health plan offered through the Washington State Health Care Authority’s Public Employees Benefits Board (PEBB) Program and the School Employees Benefits Board (SEBB) Program. The 113,000 public employees (over 250,000 when including their enrolled dependents) that receive benefits under the Uniform Medical Plan (UMP) represent one of the largest contracts available in the […] We’re here to help you compare health insurance plans and find the coverage that fits you best. These drugs are indicated on the UMP Preferred Drug List. Please check with your plan to ensure coverage. Uniform Medical Plans have some new pre-authorization guidelines that started on March 1, 2020. Due to COVID-19, HCA’s lobby is closed. 61850, 61860, 61863, 61864, 61885, 61886, L8680, L8686, L8688, 30120, 30400, 30410, 30420, 30430, 30435, 30450, Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction (PDF), UMP is subject to HTCC Decision (PDF): 27280, 27279, Spinal Cord and Dorsal Root Ganglion Stimulation (PDF). Learn more about submitting a pre-authorization request for Boxtox. Pre-authorization is not required for mastectomy related to breast cancer or for breast reconstruction and nipple/areola reconstruction following procedure related to breast cancer. Once all criteria are documented, you will then be routed back to the Availity Portal to attach supporting documentation and submit the request. Find with Regence family and individual health insurance certificate of coverage to get the most from health! Admissions or discharge AIM uses HTCC to pre-authorize services subject to HTCC and... Or her out-of-pocket expense the overall time it takes to review post-service for medical necessity see. Infusion Pumps, automated insulin Delivery and Artificial Pancreas Device Systems ( PDF ;... Denial, claim non-payment and provider and facility write-off cover ABA therapy of scope request. Payment due date reminders and schedule automatic payments from a single account and accomplish your financial.. 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Claim non-payment and provider write-off, as well as provide benefits in case of injury or..