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Guide · the basics · 4 minute read

Federal employee plan appeals

How to appeal a Federal Employees Health Benefits plan denial. Ask the carrier to reconsider within 6 months. Then ask the Office of Personnel Management to review. We also explain what a lawsuit looks like.

Applies to: Military, veteran or federal employee

Key points

  • Step one is a written request to your plan's carrier to reconsider, within 6 months of the date of the denial notice. The carrier has 30 days to answer.
  • Step two is a request to the Office of Personnel Management (OPM), usually within 90 days of the carrier's letter upholding the denial.
  • If OPM finds you are entitled to the benefit, the carrier must pay or provide it. A lawsuit goes against OPM, not the carrier, and only after both steps.
  • Check the date on your notice, which controls.
On this page 5

If you or your family get health coverage through the Federal Employees Health Benefits (FEHB) program, your appeal follows federal rules that are different from private employer plans and from state insurance law. The agency that oversees these plans is the Office of Personnel Management (OPM), not your state insurance department or the Department of Labor. The reference page is Federal Employees Health Benefits plan.

What this means

FEHB plans follow their own federal process. The plan’s contract terms on coverage and benefits override state insurance laws. The insurer that runs your plan is called the carrier. There are two steps, and then court.

  1. The carrier reconsiders its own denial.
  2. OPM reviews the carrier’s decision.

If OPM rules in your favor, each FEHB contract requires the carrier to pay or provide the service. OPM may ask an independent physician for an advisory opinion.

What to do

  1. Read the denial notice and your plan’s brochure (you). Each plan brochure has a “disputed claims” section with plan-specific addresses and any faster handling for urgent care claims. This site has not confirmed the urgent care timeframes in brochures, so read yours.
  2. Ask the carrier to reconsider, in writing (you). You have 6 months from the date of the denial notice. The carrier may extend that deadline for circumstances beyond your control.
  3. Wait for the carrier’s answer (the carrier). The carrier has 30 days after receiving your request to uphold the denial, pay or provide the service, or ask for more information. If it asks for more, it has 30 days after receiving it. If nothing arrives within 60 days, it must decide on the evidence it has.
  4. Ask OPM to review (you). You may ask OPM within 90 days after the date of the carrier’s letter upholding the denial. If the carrier did not respond, the time is 120 days after your request for reconsideration. If the carrier asked for more information, it is 120 days after that request.
  5. Wait for OPM (OPM). OPM must, within 90 days of receiving your request, either issue a written decision or tell you the status of the review. OPM’s own guidance says it generally acknowledges a request within 5 days and sends a final response within 60 days.
  6. Consider court only after both steps (you). A lawsuit must be brought against OPM, not the carrier. It must be brought no later than December 31 of the third year after the year the care was provided. Review is limited to the record before OPM, and the remedy is an order directing OPM to require the carrier to pay the disputed benefit. This is a point for a lawyer.

Check the date on your notice, which controls.

The rule

A member must ask the carrier in writing to reconsider within 6 months of the date of the denial notice. The deadline may be extended for circumstances beyond the member’s control. (Title 5 of the Code of Federal Regulations (CFR), section 890.105(b)(1))

Watch for

  • The wrong agency. State insurance departments and the Department of Labor’s Employee Benefits Security Administration are not your regulators for FEHB plans.
  • A 6-month clock, not 180 days. Do not use the 180-day figure from private employer plan guides.
  • Surprise bills. The federal surprise billing protections apply to FEHB carriers.
  • Postal Service plans. This site has not confirmed whether the Postal Service Health Benefits program follows the identical steps. Read your plan brochure.
  • A web page you cannot open. OPM’s “Disputed Claims” web page now sits behind a login and could not be read for this site. Rely on your brochure and the denial letter.
  • Documents. Ask the carrier in writing for the documents it used. The right-to-documents rules in this site’s other guides are written for private plans, and this site has not confirmed them for FEHB plans. See Ask for your claim file for how to ask.

What next

Sources

Official and primary sources used on this page. Checked 2026-11-12.

  1. 5 CFR 890.105, procedures for reconsideration and review of denied claims — Electronic Code of Federal Regulations
  2. 5 CFR 890.107, legal action — Electronic Code of Federal Regulations
  3. My plan denied my claim and I think they should have covered the services. What can I do? — Office of Personnel Management
  4. 5 U.S.C. 8902, contracts for health benefits plans — Government Publishing Office
  5. 5 CFR 890.114, surprise billing protections — Electronic Code of Federal Regulations

What next

Letters and scripts

  • Letter or script

    Ask for your claim file

    A written request for everything the plan used or created when it decided your claim, sent before you appeal. It asks for the file free of charge and says clearly that it is not an appeal.

  • Letter or script

    Request an expedited appeal

    Asks your plan to decide an appeal as an urgent claim, within 72 hours, because waiting could seriously harm your health, and to contact your doctor.

  • Letter or script

    Name someone to act for you

    A plain written statement naming a family member, friend or advocate to speak and write to your health plan for you about a claim or appeal. It does not replace the plan's own form.

Related guides

  • Guide

    Government and church employer plans

    Plans run by state and local governments, school districts and churches are outside much of ERISA. Learn which federal rules still protect you, which do not, and who to ask.

  • Guide

    TRICARE appeals

    How to appeal a TRICARE denial. Start with a written reconsideration within 90 days. Next steps differ for factual and medical necessity denials, with dollar minimums at the later levels.

  • Guide

    How to request your claim file

    Ask your plan in writing, before you appeal, for everything it used to decide your claim. Covers what to ask for, where to send it, what the rules say about cost and timing, and what to do if the plan stalls.

  • Guide

    How to get an expedited appeal

    When waiting could seriously harm your health, you can ask for a fast appeal, decided in 72 hours or less, and ask for independent review at the same time. Here is how to ask and what your doctor can do.

  • Guide

    Who regulates your plan

    Which agency oversees each kind of health coverage, and where to send a complaint. A state insurance department cannot help with every plan.

  • Guide

    Acting for someone else

    You can usually help a parent, partner or adult child with a denial if they give written permission. Here is how to name a representative with plans, Medicare and Medicaid, and what this page does not cover.

This page is general information, not legal or medical advice. Your notice, your plan document and the law that applies to your coverage control.

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