Filing
Disputed Claims If you don't agree with your health plan's
decision regarding a claim:
Check
your plan's FEHB brochure to see if the service is covered,
limited, or excluded.
Review and follow the directions
in the disputed claims section of the brochure. This section
will tell you how to ask the plan to reconsider your claim.
You must explain why (in terms of the applicable brochure
coverage provisions) you feel the services should be covered.
If the plan again denies the claim, read the plan's decision
letter carefully. Then, check your plan's brochure again.
If you still disagree with the plan's decision, the disputed
claims section of the brochure will tell you how to write
to the U.S. Office of Personnel Management to ask us to
review the claim.
When OPM receives your
claim:
One of three Insurance Contracts
Divisions in the Office of Insurance Programs will review
it.
Shortly after receiving your
request, the Contracts Division will send you an acknowldgement
(generally, within 5 days).
The Contracts Division will
send you a final response within 60 days after receiving
your request.
If the Contracts Division needs
more time or if you need to do more (such as send us additional
information) before we can reach a final decision, the Contracts
Division will contact you within 14 work days of receiving
your request and tell you what you still need to do.
You
may call the Contracts Division to check on the status of
your disputed claim review by dialing the telephone number
provided on the acknowldgement they send you. The Contracts
Division cannot give you a decision over the phone until
they have completed the review and issued a written final
decision.
