Federal agency ยท U.S. Office of Personnel Management
Office of Personnel Management: disputed claims for federal employee health plans
The Office of Personnel Management (OPM) reviews a denied claim from a federal employee health plan after the plan has reconsidered it. This page explains the order, how to write to OPM, and the response times it states.
Know before you go
This is for federal employee health plan members. You must first ask your plan to reconsider, and OPM cannot review a claim unless the plan has reconsidered it or been given the chance. The page says OPM generally acknowledges a request within 5 days and sends a final response within 60 days of completing the review, and it will not give a decision by phone. Your plan brochure's disputed claims section has the exact steps and deadlines.
- Cost
- Not stated. The page lists no fee.
- Where
- Nationwide
- How to start
- Read the disputed claims section of your plan brochure. Write to the plan first. If the plan denies again, follow the brochure's instructions to write to OPM.
- Have ready
- Your plan brochure; The plan's decision letter; Your written reasons the service should be covered under the brochure
Where this comes from
- Provider
- U.S. Office of Personnel Management
- Source we read
- https://www.opm.gov/frequently-asked-questions/insure-faq/health/my-plan-denied-my-claim-and-i-think-they-should-have-covered-the-services-what-can-i-do/
- Date we read it
- . This is not a fresh check.
- Date the provider printed
- Not displayed
- What we checked
- We read the provider's public page. We have not verified availability, eligibility or outcomes for any individual.
Other starting points
- Program or service
Beneficiary and Family Centered Care Quality Improvement Organizations: find yours
The Medicare contractors that handle fast appeals when hospital or other care is ending too soon, and complaints about the quality of care. Each state is assigned to one of two organizations.
From Centers for Medicare & Medicaid Services
- Program or service
California Department of Managed Health Care: Independent Medical Review
California's regulator for managed care plans reviews denials of medical services, emergency payment and experimental treatment through Independent Medical Review. One form starts either a review or a consumer complaint.
From California Department of Managed Health Care
- Program or service
Center for Medicare Advocacy self-help materials
Downloadable self-help toolkits for Medicare denials involving home health care, outpatient therapy and skilled nursing facility care, from a nonprofit law organization. The page describes materials, not a helpline.
From Center for Medicare Advocacy