If you file a claim under the Federal Employees Health Benefits program and it is denied, a set of appeal rights applies. First, check your plan’s brochure to see if the service is covered, limited or excluded. The next step is to review the disputed claims section of your brochure. Briefly, the disputed claims section will direct you to write to the plan to explain why (in terms of the applicable brochure coverage provisions) you feel the services should be covered, and to ask the plan to reconsider your claim.
If the plan again denies the claim, read the plan’s decision letter carefully and then check your plan’s brochure again. If you still disagree with the plan’s decision, the disputed claims section of your brochure will show you how to write to the Office of Personnel Management to ask it to review the claim. OPM can’t review a denied claim unless your plan has reconsidered it first (or at least been given an opportunity to reconsider it).
Your disputed claim will be reviewed in one of four Insurance Contracts Divisions. Generally, OPM will acknowledge your request within five days. After OPM completes the review, it will send you a final response within 60 days. If it needs more time, or if you need to do more–such as send more information–it will contact you within 14 work days of the time OPM gets your request and tells you what you still need to do, if anything. OPM will not give a decision over the phone until the review has been completed and a written copy of the final decision has been issued.
If you are not satisfied with the result of the OPM review, you may be able to challenge the claim in federal or state court, depending on the laws of your state. Consult a legal advisor if necessary.