[Code of Federal Regulations]
[Title 5, Volume 2]
[Revised as of January 1, 2005]
From the U.S. Government Printing Office via GPO Access
[CITE: 5CFR890.105]

[Page 439-441]
 
                    TITLE 5--ADMINISTRATIVE PERSONNEL
 
          CHAPTER I--OFFICE OF PERSONNEL MANAGEMENT (CONTINUED)
 
PART 890_FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM--Table of Contents
 
             Subpart A_Administration and General Provisions
 
Sec. 890.105  Filing claims for payment or service.

    (a) General. (1) Each health benefits carrier resolves claims filed 
under the plan. All health benefits claims must be submitted initially 
to the carrier of the covered individual's health benefits plan. If the 
carrier denies a claim (or a portion of a claim), the covered individual 
may ask the carrier to reconsider its denial. If the carrier affirms its 
denial or fails to respond as required by paragraph (c) of this section, 
the covered individual may ask OPM to review the claim. A covered 
individual must exhaust both the carrier and OPM review processes 
specified in this section before seeking judicial review of the denied 
claim.
    (2) This section applies to covered individuals and to other 
individuals or entities who are acting on the behalf of a covered 
individual and who have the covered individual's specific written 
consent to pursue payment of the disputed claim.
    (b) Time limits for reconsidering a claim. (1) The covered 
individual has 6 months from the date of the notice to the covered 
individual that a claim (or a portion of a claim) was denied by the 
carrier in which to submit a written request for reconsideration to the 
carrier. The time limit for requesting reconsideration may be extended 
when the covered individual shows that he or she was prevented by 
circumstances beyond his or her control from making the request within 
the time limit.
    (2) The carrier has 30 days after the date of receipt of a timely-
filed request for reconsideration to:
    (i) Affirm the denial in writing to the covered individual;
    (ii) Pay the bill or provide the service; or
    (iii) Request from the covered individual or provider additional 
information needed to make a decision on the claim. The carrier must 
simultaneously notify the covered individual of the information 
requested if it requests additional information from a provider. The 
carrier has 30 days after the date the information is received to affirm 
the denial in writing to the covered individual or pay the bill or 
provide the service. The carrier must make its decision based on the 
evidence it has if the covered individual or provider does not respond 
within 60 days after the date of the carrier's notice requesting 
additional information.

[[Page 440]]

The carrier must then send written notice to the covered individual of 
its decision on the claim. The covered individual may request OPM review 
as provided in paragraph (b)(3) of this section if the carrier fails to 
act within the time limit set forth in this paragraph (b)(2)(iii).
    (3) The covered individual may write to OPM and request that OPM 
review the carrier's decision if the carrier either affirms its denial 
of a claim or fails to respond to a covered individual's written request 
for reconsideration within the time limit set forth in paragraph (b)(2) 
of this section. The covered individual must submit the request for OPM 
review within the time limit specified in paragraph (e)(1) of this 
section.
    (4) The carrier may extend the time limit for a covered individual's 
submission of additional information to the carrier when the covered 
individual shows he or she was not notified of the time limit or was 
prevented by circumstances beyond his or her control from submitting the 
additional information.
    (c) Information required to process requests for reconsideration. 
(1) The covered individual must put the request to the carrier to 
reconsider a claim in writing and give the reasons, in terms of 
applicable brochure provisions, that the denied claim should have been 
approved.
    (2) If the carrier needs additional information from the covered 
individual to make a decision, it must:
    (i) Specifically identify the information needed;
    (ii) State the reason the information is required to make a decision 
on the claim;
    (iii) Specify the time limit (60 days after the date of the 
carrier's request) for submitting the information; and
    (iv) State the consequences of failure to respond within the time 
limit specified, as set out in paragraph (b)(2) of this section.
    (d) Carrier determinations. The carrier must provide written notice 
to the covered individual of its determination. If the carrier affirms 
the initial denial, the notice must inform the covered individual of:
    (1) The specific and detailed reasons for the denial;
    (2) The covered individual's right to request a review by OPM; and
    (3) The requirement that requests for OPM review must be received 
within 90 days after the date of the carrier's denial notice and include 
a copy of the denial notice as well as documents to support the covered 
individual's position.
    (e) OPM review. (1) If the covered individual seeks further review 
of the denied claim, the covered individual must make a request to OPM 
to review the carrier's decision. Such a request to OPM must be made:
    (i) Within 90 days after the date of the carrier's notice to the 
covered individual that the denial was affirmed;
    (ii) If the carrier fails to respond to the covered individual as 
provided in paragraph (b)(2) of this section, within 120 days after the 
date of the covered individual's timely request for reconsideration by 
the carrier; or
    (iii) Within 120 days after the date the carrier requests additional 
information from the covered individual, or the date the covered 
individual is notified that the carrier is requesting additional 
information from a provider. OPM may extend the time limit for a covered 
individual's request for OPM review when the covered individual shows he 
or she was not notified of the time limit or was prevented by 
circumstances beyond his or her control from submitting the request for 
OPM review within the time limit.
    (2) In reviewing a claim denied by the carrier, OPM may:
    (i) Request that the covered individual submit additional 
information;
    (ii) Obtain an advisory opinion from an independent physician;
    (iii) Obtain any other information as may in its judgment be 
required to make a determination; or
    (iv) Make its decision based solely on the information the covered 
individual provided with his or her request for review.
    (3) When OPM requests information from the carrier, the carrier must 
release the information within 30 days after the date of OPM's written 
request unless a different time limit is specified by OPM in its 
request.

[[Page 441]]

    (4) Within 90 days after receipt of the request for review, OPM will 
either:
    (i) Give a written notice of its decision to the covered individual 
and the carrier; or
    (ii) Notify the individual of the status of the review. If OPM does 
not receive requested evidence within 15 days after expiration of the 
applicable time limit in paragraph (e)(3) of this section, OPM may make 
its decision based solely on information available to it at that time 
and give a written notice of its decision to the covered individual and 
to the carrier.
    (5) OPM, upon its own motion, may reopen its review if it receives 
evidence that was unavailable at the time of its original decision.

[61 FR 15178, Apr. 5, 1996]