Have you ever gotten into an argument with you health benefit plan over whether a medical procedure or service should be covered? There are few things more frustrating. Speaking from experience, I can tell you that most plan decisions are correct; however, they aren’t always. And when they aren’t, the problem usually arises is in the interpretation of a contract provision. The plan says it means one thing and, you say it means another. Fortunately, there is a procedure for resolving such disputes.
If you don’t agree with your plan’s decision, you can – and should – ask them to reconsider it. The procedure for doing that is printed in each FEHB plan brochure. If the plan still doesn’t agree with you and you think that you’re right, you can – and should – write to the Office of Personnel Management (OPM) and ask them to review the claim. The information on how to do that is also in your plan brochure.
If you appeal to OPM, they will send you an acknowledgement. If they need no further information than you have provided, they’ll get a final decision to you, usually within 60 days. If they need more information either from you or the plan, they’ll let you know that within 14 days of the date they receive your appeal. They’ll even provide a phone number so you can check on the status of your claim. If the decision is in your favor, great! If it isn’t, you are free to file suit in federal district court.
FYI, the best way to get early resolution of a disputed claim is for you to carefully read the language in your plan’s brochure. Remember that the brochure is a contract, and it’s like any other contract you enter into. When there is a dispute, you must rely on the contract language to prove your point. Then marshal all the other facts supporting your side of the argument. The better you do this, the more likely you are to win in the reconsideration phase. If that doesn’t work, when you go to OPM, you’ll need to counter anything that came in the plan’s reconsideration decision. Remember, your job is to point out flaws in the plan’s arguments or point up any lack of clarity in the contract wording. Either of these should work in your favor.
One note of caution. If a medical procedure or service isn’t covered in the brochure or, worse still, specifically excluded, your hope of getting it paid for is probably zero. Nevertheless, your arguments about why it should be covered may lead to its being included in a subsequent year’s contract. Once again speaking from experience, OPM’s contracting officers have a keen interest in what should be in a contract, not just what’s in it now.