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.