Here are answers to some of the more common questions we get from our members about their health plans. If you don't see your particular question below, sign in and go to the Benefits page to view your benefit booklet, or call the Member Services number on the back of your member ID card. We are here to help.

Contact Member Services if you would like a copy of any of the information contained below.

What are my rights as a member?

You have the right to:

  • Receive information about our company and services, as well as the doctors and other providers in our network.
  • Receive information about your member rights and responsibilities.
  • Make recommendations regarding our company's rights and responsibilities policy.
  • Be treated with respect and dignity.
  • Privacy of your personal information.
  • Participate in decisions about your care with your doctor and other health care professionals.
  • Openly discuss with your doctor the appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
  • Submit complaints or appeal decisions made by your health plan or about the care provided to you.

What are my responsibilities as a member?

You have the responsibility to:

  • Give as much information as possible to your plan, doctors and other providers so they can give you the right care.
  • Follow plans and instructions for care that you and your doctor have agreed to.
  • Understand the condition of your health and participate in developing mutually agreed-upon treatment goals, as much as possible.
  • Know and confirm your benefits and eligibility before receiving services.

Which services are covered or not covered?

To see what treatments or services are covered and not covered, sign in and go to the Benefits page to view your benefit booklet, or call the Member Services number on the back of your member ID card.

What charges are my responsibility?

You are responsible for copayments, your annual deductible and any required coinsurance.

Copayments

Copayments are the fixed dollar amount that you must pay directly to the provider for an office visit, emergency room visit or prescription medication each time you receive a service or medication. To understand what copayments you are responsible for, refer to the Medical Benefits section of your benefit booklet. To find your benefit booklet, sign in to and go to the Benefits page.

Deductible

Your annual deductible is the amount you must pay each year for covered medical expenses before your health insurance starts paying its share of subsequent expenses.

Coinsurance

Once you have met your deductible and copayment, we pay a percentage of the allowed amount for covered services you receive, up to the maximum benefit. When our payment is less than 100 percent, you pay the remaining percentage (this is your coinsurance). Your coinsurance will be based upon the lesser of the billed charges or the allowed amount. The percentage we pay varies, depending on the kind of service you receive and who performs it.

We do not reimburse providers for charges above the allowed amount. However, a preferred or participating provider will not charge you for any balances.

For more information about copayments, deductibles and coinsurance specific to your plan, sign in and go to the Benefits page to view your benefit booklet, or call the Member Services number on the back of your member ID card.

How do I get care and services when I am traveling outside my service area? Are there any benefit restrictions?

You may get care and services outside of your service area through the BlueCard® program, which allows you to take your health care benefits with you when you travel in the United States and around the world. To learn more and to find out about your benefits and restrictions, visit the BlueCard information page or call the Member Services number on the back of your member ID card.

I don't speak English or am a TTY user. How do I get language help?

To get help in languages other than English, call our Member Services department at the phone number on the back of your member ID card. TTY users call 711.

Para asistencia en español, por favor llame al teléfono de Servicio al Cliente en la parte de atrás de su tarjeta de miembro.

Para humingi ng tulong sa Tagalog, pakitawagan ang numero ng telepono ng Serbisyo sa Kostumer (Member Services) na nakasulat sa likod ng inyong kard bilang miyembro.

如需中文幫助,請撥打客戶服務電話, 號碼位於您會員卡背面。

Diné kʼehjí áká'eʼyeedgo, t'áá shǫǫdí áká anídaalwoʼí bi béésh bee haneʼé ninaaltsoos bee atah nílínígíí bineʼdę̀ę̀ bikááʼ.

How do I submit a claim for covered services?

When you receive care from an in-network provider or pharmacy, they will process your claims directly with us, so you don't need to handle any paperwork.

However, if you receive care from a provider or pharmacy outside of your service area, you may have to pay at the time of service. If the bill is for covered or authorized services, you can file a claim with us for reimbursement. If you pay the bill, ask the provider's office for an itemized bill and keep a record of your payment.

To file a claim for reimbursement, follow these steps:

  1. Complete and sign the Member Reimbursement Form or the Prescription Claim Form.
  2. Enclose an itemized bill from the provider or pharmacy for the covered service,
  3. Mail your claim to the address shown on the form.

How do I get information about the providers in my network?

You can get information about providers in your network, including contact information, professional qualifications, specialty, education and board certification status in Find a doctor.

Am I required to have a primary care provider (PCP) to receive primary care services? If so, how do I find one?

Only some plans require a primary care provider (PCP). If your plan does require a PCP, you can choose one in Find a doctor. You will need to see your PCP to receive primary care services or receive a referral for medical and behavioral health care specialists or hospital services.

If your plan does not require a PCP, you may access primary care services from any doctor you choose within our network. Even if it's not required, we still recommend that you choose a PCP to help coordinate your care and provide preventative services. A PCP may also help you to find the best medical and behavioral health care specialists and to get hospital services.

For more information, sign in and go to the Benefits page to view your benefit booklet, or call the Member Services number on the back of your member ID card.

How do I find and get care from specialists, behavioral health providers and hospitals?

Your primary care provider (PCP) is the best person to help you find and get care from specialists, behavioral health care providers and hospitals. For this reason, we suggest that you establish a relationship with a PCP of your choice, even if it is not required by your plan.

If your plan requires a PCP, you must get these services through your PCP. 

If your plan does not require a PCP, you can get services directly, without referral. Use Find a doctor to look up in-network specialists and behavioral care providers..

For more information about benefits, restrictions or your provider network sign in and go to your member dashboard, or call the Member Services number on the back of your member ID card.

How do I get care outside of normal business hours?

If you have an emergency, call 911 or go to the nearest emergency room.

If you need care outside of regular business hours and it isn't an emergency situation, first call your doctor's office to see if your doctor or provider has extended office hours. If not, you may ask the answering service to have your doctor or the on-call doctor call you back.

You can also look up urgent care, walk-in and retail clinics and the hours they are open in Find a doctor.

Urgent care

Urgent care facilities offer medical care outside of a hospital emergency room, usually on an unscheduled, walk-in basis. Patients typically visit urgent care centers when they have an injury or illness that requires immediate care but is not serious enough for a visit to an emergency room. Many urgent care centers offer extended hours but are not usually open 24 hours a day like a hospital emergency room.

Walk-in clinics

Like urgent care, walk-in clinics are usually open on weekends or weekday evenings and offer walk-in appointments. These clinics offer similar services to urgent care and are often part of larger provider systems. Because of this, they are good options for patients who want their primary care physician or specialist to be informed by the walk-in clinic providers about the care they received.

Retail clinics

Also called convenient care clinics, these are health care clinics located in retail stores, supermarkets and pharmacies that treat uncomplicated minor illnesses and provide preventative health care services. They are usually staffed by certified nurse practitioners (CNPs) or physician assistants (PAs).

Advice24 (not included with all plans)

If you believe your condition is life- or limb-threatening, call 911. You do not need to call Advice24 first.

Advice24 is a toll-free, 24/7 nurse hotline that provides immediate support for everyday health issues and questions that otherwise might lead to unnecessary doctor or emergency room visits.

Our registered nurses can advise you on common issues such as:

  • Vomiting, nausea or upset stomach
  • Cuts, minor burns, scrapes
  • Colds, viruses, coughing, dizziness, headaches
  • Sore throats or flu
  • Back pain
  • Crying or feverish baby
  • Just feeling bad but you don't know why

To view information about this program, sign in and go to Advice24.

What is an emergency? When should I call 911?

A medical emergency is when you believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The symptoms may be an illness, injury, severe pain or a medical condition that is quickly getting worse. If you experience an emergency situation, call 911 or go to the nearest emergency room. If the situation is not a true medical emergency, you may use Find a doctor  to discover  the location and hours of urgent care, walk-in and retail clinics near you.

How do I get care in an emergency?

In an emergency situation, call 911 or go to the nearest emergency room. Hospital care outside of your service area is a covered benefit. In- or out-of-network benefits will apply depending on your insurance plan.

In an emergency situation prompt care comes first. But if you wish to confirm your acute care center is a covered healthcare facility, you may use Find a doctor.

How do I submit a complaint?

If you have a concern or are unhappy about the service or care provided to you by your health plan, a clinic, doctor, or any health care provider, you may submit a complaint (also called a grievance).

There are several ways to submit a complaint.

Health plan grievances

You may submit a complaint about your health plan by contacting Member Services at the phone number on the back of your member ID card. A Member Services representative can help you try to resolve your concern or, if you prefer, provide you with instruction on how to submit your grievance in writing.

Provider grievances

If you want to submit a complaint about your service or care by a clinic, doctor, or any health care provider there are two options:

  • Submit your complaint verbally, or get instruction on how to submit a complaint in writing, by contacting Member Services.
  • Submit your grievance online via secure email to your health plan by completing the correct Health Care Quality Concerns Form for your state:

For more information about submitting a complaint or grievance call the Member Services number on the back of your member ID card or follow the grievance process in your benefit booklet (available on the Benefits page after signing in).

How do I appeal a decision about my coverage, benefits or services?

You have the right to appeal or request an independent review of any action we take or decision we make about your coverage, benefits or services. You can make either a written or verbal request. Learn more on the Appeals page: Get information on time limits, understand how to make appeals, and download the appeals form.

How do you insure that I receive the highest quality care and services?

We are continually working to assess and improve the care and services you receive from your plan and your providers as well as offering tools to empower you to make strong decisions about your own care.

Member satisfaction

We check in with our members several times a year to see how they feel about our services.

Fraud & abuse prevention

Health care fraud and abuse steals billions of dollars every year from all of us. Learn more about our prevention efforts and what you can do to help.

Find a doctor

Sign in and use Find a doctor not only to search for providers covered by your plan and network, but also to read and leave reviews of those providers.

We are here to help ensure you get the best quality care. Before you head to the doctor's office or hospital here are a few more things to know before you go.

And if you do encounter a quality issue with us or a provider, we want to know. See the question above on how to submit a complaint.

How are decisions made about benefits coverage for new technology and advances in healthcare?

New technology may include but is not limited to behavioral health and medical treatments and procedures, medical devices, and pharmaceuticals. Review of new technologies occurs through referrals from our staff, the physician and provider community, and members. A review of published peer-reviewed literature for the evaluation of effectiveness and safety is conducted on all new technologies selected for review. Once approved, the policies are updated every year. This process ensures that new advancements can be included in the benefits that members receive; that members have fair access to safe and effective care; and ensures that we are aware of changes in the industry. If you have questions about the rules or restrictions, please call Member Services at the phone number on the back of your member ID card.

How is my personal health information protected?

At Regence, we know you value your privacy. That is why we are committed to the confidentiality and security of your personal information. We maintain physical, administrative and technical safeguards to protect against unauthorized access, use, or disclosure of your personal information, including information we share internally either orally, electronically or in writing. The Terms & Privacy page informs you of your rights and how we protect and use your personal information.

We take our obligation to protect your information seriously. Regence has put in place many safeguards to protect the privacy and security of your information. Our employees are required to complete privacy and security training when they are hired and to complete additional training every year. Employees are required to sign a privacy and security acknowledgement statement.

Only those employees with a business need to know have access to health information. We have a number of technical safeguards in place to protect your data including badge access areas and network security systems. We monitor our systems to make sure your information is accessed appropriately.

I'm facing a health crisis or a chronic medical condition. How do I get case management support?

If you or a family member who is on your plan faces a serious medical situation, you'll have easy access to one-on-one support at no extra cost.

Our Case Management staff, including registered nurses and clinical behavioral health specialists, are available to help guide you through the health care system and work closely with you and your doctor on a personal treatment plan. They will also work with disease and behavioral specialists to help with other chronic conditions including chemical dependency and depression. We are here to help you face any difficult medical situation.

Case Management is not insurance, but is included with your plan to help you get information and support when you need it.

For more information, or to refer yourself, visit the Case Management page or call toll-free: 1 (866) 543-5765.

What is utilization management (UM)?

Our utilization management (UM) staff evaluates the medical necessity, appropriateness, and efficiency of health care services, procedures, and facilities and works with you to make sure you receive the care you need.

UM is designed to help members to receive cost effective care based on applicable nationally recognized standards of care and evidence based guidelines, to get the best possible outcomes. The utilization management program supports compliance with regulatory standards, supports quality review processes and encourages the efficient use of financial and personnel resources by assuring that medical and behavioral health care resources are appropriately utilized. Our UM program encompasses a full spectrum of utilization management activities throughout the continuum of care to integrate medical, behavioral health, and chemical dependency reviews.

We want you to understand this process, and we welcome any feedback you may have. Please feel free to contact us at the phone number on the back of your member ID card for more information.

How can I contact my plan with questions regarding the utilization management (UM) process and authorization of care?

You may contact the Regence Utilization Management (UM) staff by calling the Member Services at the toll free phone number on the back of your member ID card.

Utilization management (UM) staff is available Mon.–Fri., 7:00 a.m.–5:00 p.m. PT, and 8:00 a.m.-6:00 p.m. MT. Staff can receive inbound communication regarding UM issues after normal business hours via voice mail and by fax. Communications received after normal business hours are returned on the next business day.

To get help in languages other than English, call our Member Services department at the phone number on the back of your member ID card. TTY users call 711.

Para asistencia en español, por favor llame al teléfono de Servicio al Cliente en la parte de atrás de su tarjeta de miembro.

Para humingi ng tulong sa Tagalog, pakitawagan ang numero ng telepono ng Serbisyo sa Kostumer (Member Services) na nakasulat sa likod ng inyong kard bilang miyembro.

如需中文幫助,請撥打客戶服務電話, 號碼位於您會員卡背面。

Diné kʼehjí áká'eʼyeedgo, t'áá shǫǫdí áká anídaalwoʼí bi béésh bee haneʼé ninaaltsoos bee atah nílínígíí bineʼdę̀ę̀ bikááʼ.

Does the plan offer incentives to staff who make UM decisions about my care and service?

No, utilization management decisions are based only on appropriateness of care and service and the existence of coverage. We do not offer rewards or incentives for practitioners, facilities, staff or other individuals for issuing denials of coverage, service or care. We do not offer financial incentives for utilization management decision-makers to encourage decisions that would result in using fewer benefits.

When is pre-authorization (also called prior authorization) required?

Some medical procedures require pre-authorization before you receive treatment in order to get coverage from your health plan. (You can use any of the benefits of this coverage without a referral, which is different from a pre-authorization.)

Pre-authorization allows us to review your treatment within the context of any other health issues you may have and to consider the latest scientific research available to manage your condition. Some conditions have a wide range of treatment choices, and some treatments work better than others. Checking in on your progress after a series of treatments helps us make sure your treatment is effective, medically necessary and right for you.

If a doctor does not get pre-authorization before treating you, your health plan will not cover those costs and the doctor may bill you for that treatment.

If you use an in-network doctor, you don't need to do anything. The doctor's office will handle the pre-authorization process. Our clinical partner evaluates your treatment plan to make sure it is the most effective treatment based on published research. Our partner also ensures that it is medically necessary and covered by your health plan.

If you use an out-of-network doctor, call the number on the back of your member ID card and we can talk with you about your options. Using an out-of-network doctor may mean higher out-of-pocket costs for you.

How to find out if a procedure requires pre-authorization

For complete information about your plan's pre-authorization requirements, sign in and go to the Pre-authorization page or call the Member Services number listed on the back of your member ID card. Because some plans have different pre-authorization requirements, it's important for you to contact us if you have any questions about your coverage. Our commitment to you is to conduct pre-authorization quickly to make sure you get the care you need when you need it.

Why do I need pre-authorization for a service or product my doctor ordered?

Our medical team works closely with your health care provider to bring them knowledge and support to make the best care decisions and protect your overall benefits. Through pre-authorization, your unique needs can be identified early so you get the right care at the right place and time. Sometimes there are alternative therapies that might work better and pre-authorization gives your doctor a chance to consider your needs holistically and in the context of your overall benefits package.

These treatments, services and equipment may require pre-authorization:

  • Some surgeries and reconstructive surgery
  • Planned admission into hospitals or skilled nursing facilities
  • Transplant and donor services
  • Specialized imaging such as MRIs, CT scans and cardiac imaging
  • Non-emergency air ambulance transport
  • Prosthetics and some orthotics
  • Home medical equipment
  • Interventional pain procedures
  • Physical medicine services such as physical therapy and chiropractic care
  • Sleep studies

These prescription medications may require pre-authorization:

  • Some high-cost injectable medications
  • Specialty drugs

How do I get information about my pharmacy coverage?

For a more detailed description of your pharmacy benefits such as co-payments, deductibles, and what benefits and services are covered and not covered, sign in and view your benefit booklet on the Benefits page or call the Member Services number on the back of your member ID card.

Visit the Pharmacy benefits page for information about OmedaRx, our pharmacy benefits manager. The pharmacy benefits manager can help you with:

  • Locating a pharmacy
  • Viewing the formulary (drug list) and available generics, including formulary updates and communications
  • Prior authorization instructions (pre-authorizations) and medication limits on doses or refills
  • Instructions for your provider to request an exception
  • Process for generic substitution, therapeutic interchange & step-therapy protocols
  • Instructions on how to order specialty medications
  • Information on the Half Tablet program

How do I fill a prescription?

To fill a prescription, bring your prescription to a network pharmacy near you and show your member ID card. For information on how to find a network pharmacy, fill prescriptions by mail order or fill specialty medications, see the Pharmacy benefits page.

What medications are covered by my pharmacy plan?

See the Pharmacy benefits page for information about the covered medications of your pharmacy plan.

How do I know if my prescribed medication requires pre-authorization?

Some medications require pre-authorization (also called prior authorization) in order to be covered by your insurance plan. See the Pharmacy benefits page for information about the covered medications that may require pre-authorization.

Are there limits on how often I can refill a prescription or how much medication I can pick up each time I fill a prescription?

Yes, there are usually limits on how often you can refill a prescription. Some medications also have limits on how much medication you can pick up each time you fill your prescription. To find out more, see the Pharmacy benefits page.

How can I find out the cost of my prescribed medication before I pick it up? How do I know if a generic version of the medication is available?

See the Pharmacy benefits page for information about how OmedaRx, our pharmacy benefit manager, offers a price guide for the average price of common medications and a list of generic medications.

What is your quality improvement program for care and service, and what are its goals, processes and outcomes?

We work to improve the quality of members' medical and mental health care, safety and service so that their health and well-being improves. Our quality program describes the goals, objectives and the processes we use. The quality program includes ways to measure how we are improving quality and safety and to measure that members are getting the appropriate care and service.

Our quality improvement goals are:

  • Improve quality of care
  • Monitor and improve patient safety
  • Improve member experience
  • Provide appropriate services for different cultures and languages
  • Improve the delivery of care for people with complex health needs
  • Provide a network of high quality providers and practitioners
  • Monitor and improve mental health care
  • Meet regulatory and other health plan requirements

Our 2016 Regence quality program had these important results and accomplishments:

  • We achieved National Committee for Quality Assurance (NCQA) Accreditation for all four plans.
  • Telehealth services were introduced to improve getting care quickly.
  • We streamlined call centers to be more efficient.
  • We applied new processes to evaluate and improve communication between medical and mental health doctors and health care providers.
  • We measured and evaluated how well doctors and health care providers followed national clinical practice guidelines.
  • We surveyed our members to learn their experiences with mental health care and find ways to improve care and service.
  • We fulfilled or exceeded all our goals to provide good access to urgent, routine and preventive care appointments with primary care providers.

During 2017, we will use our quality program to continue to improve the quality and safety of care and service for members. We will add to and change the program to improve it based on the new information we learned during 2016. For more information about our quality program or to get a paper copy of our quality program annual report, call the Member Services number on the back of your member ID card.

Get the most out of your coverage

Why your network matters