528 Employee Appeals

 

528.1 Appeal of Refusal to Allow Enrollment or Change of Enrollment

Employees may request reconsideration of an employing office’s refusal to permit them to enroll or to change enrollment. The request is made in writing and sent within 30 days of the employing office’s letter of denial to the area Human Resource address identified in the denial letter. Requests must include the employee’s date of birth, name of plan, reasons for the request, and a copy of the denial letter. The decision rendered by the area office is final.

528.2 Appeal of Claim Denial

528.21 Initial Appeal Rights

528.211 Request for Reconsideration

The appropriate health plan adjudicates claims for payment or service. If a claim (or portion of a claim) or a service is initially denied by a health benefits plan, the plan reconsiders its denial upon receipt of written request for reconsideration from the employee within 1 year of the denial. The written request must state, in terms of applicable brochure provisions, the reasons the employee believes the denied claim or service should have been paid or provided.

528.212 Health Plan Responsibility

The health plan acts as follows:

1. The plan affirms the denial in writing to the employee setting out in detail the reasons, within 30 days after receipt of the request for reconsideration, or pay, or provide the claim or service within such time unless it requests additional information reasonably necessary for a determination.
2. Requests for additional information by the plan specifically identify the additional information required and the reason it is needed. If the information requested is not supplied within 60 days of the request, the plan makes its determination and notifies the employee.
3. When the plan affirms a denial after reconsideration, it provides written notice to the employee of the right to request a review of this determination by OPM.

528.22 Request for Office of Personnel Management Review

528.221 Cause for Request to Review

If a plan either affirms its denial of a claim or if its fails to respond to a written request for reconsideration within 30 days of the request, the employee may submit a written request for a review to determine whether the plan’s denial is in accord with the terms of the contract with the health benefits plan to:

INSURANCE REVIEW DIVISION
OFFICE OF PERSONNEL MANAGEMENT
PO BOX 436
WASHINGTON DC 20044–0436

The request must specifically identify the claim to be reviewed and include a copy of the employee letter to the plan with copies of any correspondence from the plan regarding its denial.

528.222 Time Limit

A request for review is not honored if received by OPM more than 90 days from the date of the plan’s affirmation of the denial.

528.223 Authorization for Release of Medical Information

A request for review is not honored if, upon request by OPM, the employee does not furnish authorization signed by the patient (or person capable of acting for the patient) for the release of medical evidence to OPM.

528.224 Office of Personnel Management Responsibility

OPM acts as follows:

1. In reviewing a claim denied by a plan, OPM reviews copies of all original evidence and findings upon which the plan denied the claim and any additional evidence submitted to OPM or otherwise obtained by the plan or OPM. Plans release such evidence and findings to OPM within 30 days of request. Any evidence obtained by OPM in connection with a review of the denied claim is held privileged and confidential and is reviewed only by persons having official need to see it.
2. In reviewing a claim denied by a plan, OPM may request the employee to obtain and submit additional medical or hospital records. OPM may also request a confidential advisory opinion from an independent physician or such other information or evidence as may, in OPM’s judgment, be required to evaluate the claim denial. An OPM request for an advisory opinion does not disclose the identity of the claimant or patient, the plan, or any medical institutions or physicians involved in the claim.
3. Within 30 days after all evidence requested by OPM has been received, it notifies the employee and the plan of its findings on the review.