Expert's View

The Federal Employees Health Benefits program is one of the best run operations in government. Among other things, it annually secures better premium rates that the private sector and assures that benefits are promptly and accurately handled by all the plans in the program. However, if you or one of your loved ones has had health problems and a request for coverage or payment was rejected by your FEHB plan, either completely or in part, what do you do?

Well, the first thing to do is to pull out your plan brochure and go to the section on disputed claims. There you’ll find an explanation of the process. In most cases, it reads something like this:

Write to us at the address shown on your explanation of benefits form within 6 months of the date of our decision, including a statement about why you believe our decision was wrong, citing specific benefit provisions in the brochure, and including copies of documents that support your claim.

The plan then has 30 days from the time they receive your request to either 1) pay the claim, precertify your hospital stay, or grant prior approval for a service, drug or supply, 2) ask you or your provider for more information or 3) continue to deny your request.

If you are asked for more information, you have 60 days to get it to them; and they have 30 days in which to respond. If you don’t agree with their decision, your next step is to write to the Office of Personnel Management asking them to review it.

To get that review, you have to write to OPM within 90 days after you get the plan’s letter upholding its decision (or 120 days from when you first wrote the plan if they didn’t meet their 30-day standard or after they asked for additional information).

When OPM receives your letter, you’ll get an acknowledgement by return mail. On it will be a phone number you can call to check the status of your disputed claim. I recommend that you not rush to the phone. Be patient. Your case worker needs time to review the package, which is only one of many he or she is handling. However, if time drags on, then you should call to find out why. Then if nothing happens, even with repeated calls or letters, it may be time to escalate the matter.

Begin by writing to the head of the organization explaining the problem. That would be Robert F. Danbeck, Associate Director, Division for Human Resources Products and Services, OPM, 1900 E Street, NW, Washington, DC 20415. Your letter will cause pressure to be put on the staff handling your claim. If you don’t get a speedy resolution, go to stage two. Write the head of OPM. Her name is Linda M. Springer. Just write her at the address above. Agency heads expect an even faster response from staff than does the organization’s top manager. It’s rare that any matter needs to be pursued beyond this level.

Of course, you can write to your Member of Congress and ask him or her to intercede for you. However, from long experience running the program, I can tell you that this rarely gets faster results than staying within OPM’s own system. In general, congressional inquiries only create an additional layer of paperwork that needs to be cleared away when providing you with an answer.

Once you have received a decision from OPM, there’s only one place to go if you’re unhappy with it. That’s the federal district court that serves your area of the country. If you decide to go that route, you’ll have to file your complaint by December 31 of the third year after the one in which the dispute arose.