Review of Claims

Read the plan brochure to become familiar with your plans benefits and claims procedures. Questions concerning benefits, claim payments and claim processing must be addressed to your plan. The Office of Personnel Management (OPM) does not pay or process claims.

If your plan denies your claim for payment or for service, it will reconsider the denial upon receipt of a written request within one year of the denial. The written request should state, in terms of applicable brochure provisions, the reason you believe the denied claim for payment or service should have been paid or provided. Within 30 days after receipt of your request for reconsideration, the plan must affirm the denial in writing to you, pay the claim, provide the service, or request additional information from you or your health care provider reasonably necessary for making a determination. (Your plan must notify you if it has requested additional information from your provider.) If this information is not supplied within 60 days, the plan will base its decision on the information it has on hand. If the plan affirms its denial, you have a right to a review by OPM to determine whether the plan has acted in accordance with its contract. Before seeking OPM review of a claim, these are some of the things you should keep in mind:

• Do not submit initial bills from providers for payment to the below address or any other office within OPM; send them to the plan along with the appropriate claim form.

• Providers may use this procedure only on behalf of and with the specific written consent of the member, and are required to demonstrate that the member has assigned all of his or her rights to the provider with regard to that particular claim.

• You should first check with your provider or facility to be sure the plan was billed correctly; for instance, was the correct procedure code(s) used, were complications correctly indicated on the billing or operative report, etc. Reasonable and customary (R&C) allowances determined and controlled solely by the plan based upon information available to it.

Along with your request for review, you must send a copy of the plan's reconsideration decision. OPM review may be obtained by writing to:

U.S. Office of Personnel Management

Insurance Review Division

Retirement and Insurance Group

P.O. Box 436

Washington, D.C. 20044

OPM must receive your request for review, along with a copy of your letter to the plan and its reply, within 90 days of the plan's affirmation of the denial. You may also ask OPM for a review if the plan fails to respond within 30 days to your written request for reconsideration or within 30 days after you have supplied additional information. In this case, OPM must receive a request for review within 120 days of your request to the plan for reconsideration or the date you were notified that the plan needed additional information. In your request for review, show (1) the date of your request to the plan or (2) the dates the plan requested and you provided additional information to the plan. OPM will notify you and the plan of its decision.

H you decide to seek judicial review of the denial of a claim, you must file suit no later than December 31 of the third year after the year in which the care or service was provided, or two years after a final determination has been made on the claim by OPM through the disputed claims process, whichever is later. Federal law governs claims for relief that relate to benefits under an FEHB plan. Damages recoverable under Federal law are limited to the amount of benefits in dispute, plus simple interest and court costs. Under Federal regulations (5 CFR 890.107), such legal actions should be brought against the carrier of your plan.

Privacy Act Statement -- if you request OPM to review a denial of a claim for payment or service, OPM is authorized by chapter 89 of title 5, U.S. Code, to use the information collected from you and the plan to determine if the plan has acted properly in denying you the payment or service, and the information so collected may be disclosed to you and/or the plan in support of OPM's decision on the disputed claim.