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Appeals Information

Follow this Federal Employees Health Benefits program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies, including a request for preauthorization/prior approval.

How to File an Appeal

Step 1:

Ask us in writing to reconsider our initial decision. You must:

  • Write to us within 6 months from the date of our decision.
  • Send your request to us at:
    MHBP
    P.O. Box 8402
    London, KY 40742
  • Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure
  • Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.
  • Include your email address (optional), if you would like to receive our decision by email. Please note that by giving us your email, we may be able to provide our decision more quickly.
  • We will provide you, free of charge and in a timely manner, any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in Step 4.

Step 2:

In the case of a post-service claim, we have 30 days from the date we receive your request to:

  • Pay the claim, 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 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.

Step 3:

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

  • 90 days after the date of our letter upholding our initial decision, or
  • 120 days after you first wrote to us, if we did not answer that request in some way within 30 days, or
  • 120 days after we asked for additional information

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, Health Insurance 2, 1900 E Street, NW, Washington, DC 20415-3620.

Send OPM the following information:

  • A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure
  • Copies of documents that support your claim, such as physicians’ letters, operative reports, bills, medical records, andexplanation of benefits (EOB) forms
  • Copies of all letters you sent to us about the claim
  • Copies of all letters we sent to you about the claim
  • Your daytime phone number and the best time to call
  • Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

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 health care professional with knowledge of your medical condition may act as your authorized representative without your 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.

Step 4:

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. 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 can not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not sue 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.

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 800-410-7778. We will hasten our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s Health Insurance 2 at 202-606-3818 between 8 a.m. and 5 p.m. eastern time.

MHBP Information on Claims and Appeals to the U.S. Office of Personnel Management

Sections 3 and 7 of the Standard Option/Value Plan brochure, or Sections 3 and 7 of the Consumer Option brochure explain how to file a claim with us. Section 8 of the Standard Option/Value Plan brochure, or Section 8 of the Consumer Option brochure, explains your rights to ask us to reconsider our claim decision and how to appeal to the U.S. Office of Personnel Management (OPM) for review of our reconsideration decision for your claim. See below for more information on your rights under the disputed claims process.

Immediate appeals Our claims and appeals process, set forth in your Plan brochure, is required to comply with rules set forth under the Patient Protection and Affordable Care Act. If you believe that we have violated our claims or appeals procedures, or that our procedures are deficient, you may immediately appeal to OPM. However, if OPM finds that we are in “substantial compliance” with these rules, OPM may reject your immediate appeal. We will be in “substantial compliance” if our failure or violation is 1) minor; 2) non-prejudicial; 3) attributable to good cause or matters beyond our control; 4) in the context of an ongoing good faith exchange of information; and 5) not part of a pattern or practice of non-compliance.

You are entitled, upon written request, to an explanation of our basis for asserting that our procedures are substantially compliant. You may contact MHBP, PO Box 8402, London, KY 40742 to request an explanation.

If OPM rejects your request for immediate review on the basis that we met the standard, you maintain the right to resubmit and pursue your claim and appeal through our claims and appeals process, set forth in your Plan brochure.

You may send an appeal to OPM at:

United States Office of Personnel Management Healthcare and Insurance Health Insurance Group II, 1900 E Street NW, Washington, DC 20415-3610

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to each claim.

Note: If anyone other than yourself wishes to file a disputed claim on your behalf with OPM, such as medical providers, that representative must include a copy of your specific written consent with the review request. However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Time Periods for Claims Sections 3 and 7 of the Standard Option/Value Plan brochure, or Sections 3 and 7 of the Consumer Option brochure, explain how to file a claim with us. We are required to meet the timeframes for claims filed, listed in sections 3 and 7 of your Plan brochure, or you may immediately appeal to OPM as explained above. Any time periods for benefit or appeal determinations in the brochure begin at the time a claim for benefits or appeal is filed in accordance with these claims procedures, without regard to whether we receive all information necessary to process a claim. If the information we need to make a decision on your claim is not included with your claim, we may request an extension including a request for the specific information. In such cases, the period for making the determination will be delayed.

Note: The deadlines found in Section 8 of the Standard Option/Value Plan brochure, or Section 8 of the Consumer Option brochure, still apply to your claim, but these deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

Full and fair review

You or your authorized representative have the right to ask us to reconsider our claim decision as described in Section 8 of the Plan brochure. To help you prepare your reconsideration request, 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 contact our Customer Service Department by writing to MHBP, PO Box 8402, London, KY 40742 or by calling 800-410-7778.

We are required to provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim. We will also provide you, free of charge and in a timely manner, with any new rationale for our claim decision. We will provide this information sufficiently in advance of the date by which we are required to provide you with our reconsideration decision to allow you reasonable opportunity to respond prior to that date. We will identify for you the medical or vocational experts whose advice we obtained in connection with the initial decision.

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 health care 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.

If we do not substantially comply with these requirements, you may be able to immediately appeal to OPM as explained above.

Avoiding conflicts of interest

Our reconsideration decision will not afford deference to the initial decision and will be conducted by a plan representative who is neither the individual who made the initial decision that is the subject of the reconsideration, nor the subordinate of that individual.

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.

If we do not substantially comply with these requirements, you may be able to immediately appeal to OPM as explained above.

Notice Requirements

We must make notices available to you in any language where 10 percent or more of the population of your county is literate only in the same non-English language as determined by the Secretary of Health and Human Services. We will include, in the English versions of all notices, a statement in any applicable non-English language clearly indicating how to access language services, including how to request a copy of the notice in any applicable non-English language. We must also provide oral language services (such as a telephone customer assistance hotline) that include answering questions in any applicable non-English language and providing assistance with filing claims and appeals (including external review) in any applicable non-English language.

Any notice of an adverse benefit determination or reconsideration confirming an adverse benefit determination we send must include information sufficient to identify the claim involved (including the date of service, the health care provider, the claim amount (if applicable), and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning).

If we do not substantially comply with these requirements, you may be able to immediately appeal to OPM as explained above.