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Disputed Claim Process

How to file internal and external appeals

Information on Claims and Appeals to the Office of Personnel Management

Sections 3, 7 and 8 of the Plan brochure explain how to file a claim with us. Section 8 of your Plan 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 Appeal

Our claims and appeals process, set forth in Section 8 of the 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 may send an appeal to OPM at:
United States Office of Personnel Management
Healthcare and Insurance
Health Insurance Group 3
1900 E Street, NW, Washington, DC

You are entitled, upon written request, to an explanation of our basis for asserting that our procedures are substantially compliant. You may contact Customer Service at 1-800-537-9384 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.

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.

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