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Your disputed claim will be reviewed in one of three Health Insurance Groups. Generally, we will acknowledge your request within 5 days. After we complete the review, we will send you a final response within 60 days. If we need more time before we can decide, or if you need to do more -- such as send us more information -- before we can decide, we will contact you within 14 work days of the time we get your request and tell you what you still need to do, if anything. We are sorry but we cannot give you a decision over the phone until the review has been completed and a written copy of the final decision has been issued.
Because of the discounts that a plan realizes through its contracts with PPO providers, the plan is able to reimburse a higher percentage of the negotiated PPO allowance when PPO providers are utilized. It would not be cost effective for the plan to reimburse at the higher level when the provider is not giving a discount. Furthermore, much of the benefit you receive from using PPO providers comes from the PPO provider's agreement not to bill you for more than the negotiated PPO allowance. Non-PPO providers are under no such obligation. In some areas of the country, it is much more difficult for a plan to arrange PPO contracts for all types of services. In areas where there are no PPO providers, you can still receive your plan's regular benefits, as opposed to the incentivized PPO benefit. If you are overseas, check with your plan to see how they pay the claims of non-PPO providers – some plans have special reimbursement allowances for overseas claims.
If you disagree with the plan’s decision on your claim, the Federal Employees Health Benefits (FEHB) Program provides for an appeal process. Check your plan’s FEHB brochure to see if the service is covered, limited, or excluded. Review and follow the directions in the disputed claims section (Section 8) of the brochure. This section will tell you how to ask the plan to reconsider your claim. You must explain why (in terms of the applicable brochure coverage provisions) you feel the services should be covered.
If the plan again denies the claim, read the plan's decision letter carefully. Then, check your plan's brochure again. If you still disagree with the plan's decision, the disputed claims section of the brochure will tell you how to write to the U.S. Office of Personnel Management to ask us to review the claim.
It depends. FEHB law requires a retiring employee to be covered under FEHB for the 5 years of service immediately before retirement or, if less than 5 years, for all service since the employee’s first opportunity to enroll in FEHB. In the above situation, the employee’s 2 years of previous FEHB coverage would count toward his 5-year FEHB coverage requirement if he had a break in service and therefore could not have had FEHB as an employee.
For example: The employee was enrolled in FEHB from 2003-2005 and then separated from Federal employment. He returned to Federal service in 2010 and was enrolled in FEHB from 2010-2013. The 2 years he was enrolled in FEHB from 2003-2005 along with the 3 years he was enrolled in FEHB from 2010-2013 enable him to meet the 5-year coverage requirement.
However, if the employee had been continuously employed and eligible for FEHB, but had a break in his FEHB coverage from 2003-2009 because he cancelled his FEHB, he would have to begin the 5-year period over again.
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