Coverage type · Military, veteran or federal employee
Federal Employees Health Benefits plan
Coverage for federal workers through a private carrier. Ask your carrier in writing to reconsider within 6 months of the date on the denial notice. If the carrier says no again, the Office of Personnel Management reviews it.
On this page 7
- Who has this
- People covered by a plan in the Federal Employees Health Benefits program.
- Who regulates it
- The United States Office of Personnel Management. Contract terms on coverage and benefits in these plans override state insurance laws.
- Can your state help?
- No. The appeal steps are federal and end with the Office of Personnel Management, and the plan contract overrides state insurance laws. Your state insurance department is not the place for this appeal. Find your state.
How to tell this is your coverage
- Your coverage is a plan in the Federal Employees Health Benefits program, and a plan brochure explains your benefits.
- The plan brochure has a disputed claims section with the plan's own addresses, and may describe faster handling for urgent care claims.
- Your denial comes from the carrier (the insurance company running your plan), which follows a federal process rather than your state's.
The appeal steps, in order
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Ask the carrier to reconsider
Official name: Request for reconsideration
- Who decides
- Your plan's carrier
- Your deadline
- In writing within 6 months of the date of the denial notice. The deadline may be extended for circumstances beyond your control. Check the date on your notice, which controls.
- Their deadline
- 30 days after the carrier receives your request, to affirm the denial, pay or provide the service, or ask you for more information. If it asks for more information, it has 30 days after receiving it. If nothing arrives within 60 days, it must decide on the evidence it has.
- What to send
- A written request for reconsideration, using the address in your plan brochure's disputed claims section. Include the denial notice, your records and a letter from your doctor. Keep proof of the date you sent it.
- If you lose, or hear nothing
- If the carrier upholds the denial, ask the Office of Personnel Management to review it.
- The rule
- 5 CFR 890.105, reconsideration by the carrier
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Review by the Office of Personnel Management
Official name: Office of Personnel Management review of a disputed claim
- Who decides
- The United States Office of Personnel Management. It may get an advisory opinion from an independent physician, and each plan contract requires the carrier to pay or provide a service if the Office finds you are entitled to it.
- Your deadline
- 90 days after the date of the carrier's letter upholding the denial. If the carrier did not respond, 120 days after your request for reconsideration. If the carrier asked for more information, 120 days after that request. Check the date on your notice, which controls.
- Their deadline
- Within 90 days of receiving your request, the Office must either issue a written decision or tell you the status of the review. The Office's own guidance says it generally acknowledges a request within 5 days and sends a final response within 60 days.
- What to send
- A written request to the Office with the carrier's denial letter, your request and the carrier's response, and the evidence you gave the carrier. Plan the request around the record, because a court reviews only the record before the Office.
- If you lose, or hear nothing
- If the Office upholds the denial, you can sue the Office, but only after both the carrier step and the Office step are finished.
- The rule
- 5 CFR 890.105, review by the Office of Personnel Management
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Federal court
Official name: Lawsuit against the Office of Personnel Management
- Who decides
- A federal court. The lawsuit is brought against the Office of Personnel Management, not the carrier.
- Your deadline
- No later than 31 December of the third year after the year the care was provided, and only after both the carrier and the Office steps are done. Check the date on your notice, which controls.
- Their deadline
- The court sets its own schedule. Review is limited to the record before the Office.
- What to send
- A complaint filed in court, which follows the court's own rules. Talk to a lawyer or free legal aid before filing.
- If you lose, or hear nothing
- The remedy is an order directing the Office to require the carrier to pay the disputed benefit. This is the last level.
- The rule
- 5 CFR 890.107, legal actions
If waiting could harm your health
We did not find a separate fast appeal in the rules we read. Your plan brochure's disputed claims section may describe faster handling for urgent care claims, but we could not confirm those timeframes. Call your plan right away, ask what it offers for an urgent request, and ask your doctor to write down why the care cannot wait. Check the date on your notice, which controls.
Free help for this coverage
- Office of Personnel Management
Reviews disputed claims after the carrier's decision. Its page on what to do when a plan denies a claim explains the steps.
- Your plan brochure
The disputed claims section has your plan's addresses for a reconsideration request.
- Legal aid
Free civil legal help for people with low incomes. A program can advise you on an appeal, but it cannot take every case. Your state page lists legal aid programs for your state.
Who this covers
This page is for people whose health coverage comes from a plan in the Federal Employees Health Benefits program. Read the federal employee plan appeals guide.
How to tell this is your coverage
Your coverage is a plan in the Federal Employees Health Benefits program, and your plan brochure describes your benefits and has a disputed claims section. The denial comes from the carrier. Use the coverage type finder if you are not sure.
What does not apply to you
The 180-day rule that applies to many employer and individual plans does not apply here. This program uses 6 months from the denial notice. The state external review process and your state insurance department do not handle this appeal. The federal rules that protect people from surprise bills for some out-of-network care apply to these carriers.
We could not confirm whether the Postal Service Health Benefits program follows these same steps. If your plan is a Postal Service plan, read your brochure and ask the Office of Personnel Management.
Where people go wrong
- Skipping the carrier step. You must ask the carrier first. The Office of Personnel Management review comes after the carrier’s decision.
- Missing the Office’s deadline. It is 90 days from the carrier’s letter, but 120 days if the carrier never responded or asked for more information. Count from the right date.
- Suing the carrier. A lawsuit must be against the Office of Personnel Management, only after both steps, and review is limited to the record before the Office. Send everything to the Office.
- Using the wrong address. Each plan’s brochure has its own disputed claims addresses. The Office’s own disputed claims web page now sits behind a login, so we could not read it.
Free help is listed above.