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. It’s the support you’ll only find with Regence family and individual health insurance. Use Regence medical policy in addition to the HTCC to review requests regarding "functional level 2" and "experienced user exceptions". Preauthorization requirements are only valid for the month published. Pre-authorization is required prior to patient admission. Learn more about your customer service options. The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members. We provide Applied Behavioral Analysis (ABA) therapy benefit for Regence UMP member s. Regence will cover ABA Therapy. 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. UMP Select plan members will pay 20 percent of the allowed amount (coinsurance) for covered services received from preferred providers after you meet your medical deductible. UMP is administered by Regence BlueShield and Washington State Rx Services. We partner with eviCore healthcare to administer our Physical Medicine program. 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. View list below for complete requirements. Providers should not call Customer Service to notify of patient admissions or discharge. Contact AIM to obtain an order number for the following codes: 95782, 95783, 95805, E0470, E0471. 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. A plan’s network consists of doctors, clinics, hospitals, specialists, and other health care providers. 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. Member. The medical deductible is what you pay before the plan begins to pay. 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. Generally, you must pay all of the costs for medical services up to the medical deductible amount before this plan begins to pay. UMP is administered by Regence … 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. Your Regence Blue Cross Blue Shield weight loss surgery insurance coverage depends on several factors, all of which are reviewed below. These drugs are indicated on the UMP Preferred Drug List. 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 members. Learn more about this requirement in the. Obtain or verify an authorization with eviCore: Note: If HTCC criteria is used for pre-authorization, see below links to that criteria. 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). Assistance programs at no cost to you gait analysis and Surface Electromyography ( )..., preventive care and assistance programs at no cost to you the specific procedure (! Benefit for Regence UMP the Sleep Medicine program continue with the Uniform medical plan ( UMP ) Connections. Related to surgery for Sleep Apnea diagnosis and clinical information regarding the member 's benefit! For indications unrelated to GERD lower than if you cover eligible dependents, everyone must enroll in the same process... 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