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Dispute a Claim
There are times when you may not agree with the outcome of a pre-service or post-service claim. When this occurs, it is important that you know how file a dispute with the local Plan. The following types of disputes are available to you based on the type of claim being reviewed. You may also call the customer service number on the back of your ID card for additional information.
The first type of dispute available is a dispute of a pre-service claim denial. A pre-service claim is one that requires you or your provider to contact the local Plan to receive precertification for inpatient stays, or prior approval for other services where failure to obtain precertification or prior approval results in a reduction or denial of benefits. Sometimes, these claims can be considered urgent which require an expedited review.
If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of Other services, you may request a review by following the procedures listed below. Note that these procedures apply to requests for reconsideration of concurrent care claims as well. (If you have already received the service, supply, or treatment, then your claim is a post-service claim and you must follow the entire disputed claims process detailed in Section 8 of the Service Benefit Plan brochure).
Download a Summary of the Disputed Claims Process
In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to:
- Precertify your inpatient admission or, if applicable, approve your request for prior approval for the service, drug or supply; or
- Write to you and maintain our denial; or
- Ask you or your provider for more information.
You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
To file an appeal with OPM
After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of the Service Benefit Plan brochure.
Note: If you are enrolled in our Medicare PDP EGWP and do not agree with our benefit coverage decision, you have the right to appeal. See below for information about the PDP EGWP appeal process.
The Disputed Claims Process
Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs, or supplies have already been provided). In Section 3, If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, drugs, or supplies that must have precertification (such as inpatient hospital admissions) or prior approval from the Plan.
You may appeal directly to the U.S. Office of Personnel Management (OPM) if we do not follow required claims processes. For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7, and 8 of the Service Benefit Plan brochure, please call your Plan’s customer service representative at the phone number found on your identification card, plan brochure, or plan website www.fepblue.org.
To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your request, please call us at the customer service phone number on the back of your ID card, or send your request to us at the address shown on your explanation of benefits (EOB) form for the Local Plan that processed the claim (or, for Prescription drug benefits, our Retail Pharmacy Program, or the Specialty Drug Pharmacy Program).
Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.
When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.
Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or their subordinate, who made the initial decision.
We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.
If you do not agree with OPM’s decision, your only recourse is to file a lawsuit. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies, or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claims decision. This information will become part of the court record.
You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.
Please remember that we do not make decisions about Plan eligibility issues. For example, we do not determine whether you or a family member is covered under this Plan. You must raise eligibility issues with your agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant, or the Office of Workers’ Compensation Programs if you are receiving Workers’ Compensation benefits.
When a claim is denied in whole or in part, you may appeal the denial. To learn more about your rights and how to file a dispute, please follow the instructions found on the MPDP Appeal Request Document.
Because your Medicare drug plan has upheld its initial decision to deny coverage of, or payment for, a prescription drug you requested, or upheld its decision regarding an at-risk determination made under its drug management program, you have the right to ask for an independent review of the plan’s decision. You need the form to request an independent review of your drug plan’s decision. You have 60 days from the date of the plan’s Redetermination Notice to ask for an independent review. Please complete the form and mail or fax it as instructed. They will review your request and provide you with a decision and further instructions on next steps if you still disagree with the outcome. For additional assistance, please call us at 888-338-7737, TTY: 711.
The Disputed Claims Process
Please follow this Postal Service Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs, or supplies have already been provided). In Section 3, If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, drugs, or supplies that must have precertification (such as inpatient hospital admissions) or prior approval from the Plan.
You may appeal directly to the U.S. Office of Personnel Management (OPM) if we do not follow required claims processes. For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7, and 8 of the Service Benefit Plan brochure, please call your Plan’s customer service representative at the phone number found on your identification card, plan brochure, or plan website www.fepblue.org. If you are a Postal Service annuitant, or their covered Medicare-eligible family member, enrolled in our Medicare Part D Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) and you disagree with our pre-service or post-service decision about your prescription drug benefits, please, follow Medicare's appeals process outlined in Section 8(a), Medicare PDP EGWP Disputed Claims Process.
To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your request, please call us at the customer service phone number on the back of your ID card, or send your request to us at the address shown on your explanation of benefits (EOB) form for the Local Plan that processed the claim (or, for Prescription drug benefits, our Retail Pharmacy Program, or the Specialty Drug Pharmacy Program).
Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.
When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.
Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or their subordinate, who made the initial decision.
We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.
If you do not agree with OPM’s decision, your only recourse is to file a lawsuit. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies, or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claims decision. This information will become part of the court record.
You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.
Please remember that we do not make decisions about Plan eligibility issues. For example, we do not determine whether you or a family member is covered under this Plan. You must raise eligibility issues with your agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant, or the Office of Workers’ Compensation Programs if you are receiving Workers’ Compensation benefits.
Reminder: If you are a Postal Service annuitant, or their covered Medicare-eligible family member, enrolled in our Medicare Part D PDP EGWP you may appeal an adverse pre-service or post-service determination through Medicare's appeals process. See Section 8(a).
When a claim is denied in whole or in part, you may appeal the denial. To learn more about your rights and how to file a dispute, please follow the instructions found on the MPDP Appeal Request Document.
Because your Medicare drug plan has upheld its initial decision to deny coverage of, or payment for, a prescription drug you requested, or upheld its decision regarding an at-risk determination made under its drug management program, you have the right to ask for an independent review of the plan’s decision. You need the form to request an independent review of your drug plan’s decision. You have 60 days from the date of the plan’s Redetermination Notice to ask for an independent review. Please complete the form and mail or fax it as instructed. They will review your request and provide you with a decision and further instructions on next steps if you still disagree with the outcome. For additional assistance, please call us at 888-338-7737, TTY: 711.
Explanation of Benefits (EOBs)
An EOB is an outline of what services you received from a provider and how your benefits were applied to cover those services. You can view your personal EOBs through your MyBlue account.
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