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If you are enrolled in a Multi-State Plan (MSP) option and your claim or request for health care has been denied by your insurance company, you may ask the U.S. Office of Personnel Management (OPM) to independently review that decision. This process is called External Review and is free to all enrollees.
OPM will review whether your insurance company’s denial was justified by examining the terms of coverage and the specific circumstances surrounding the denial. If medical expertise is needed for review of a denial, OPM will seek the opinion of a contracted Independent Review Organization (IRO). In most cases, OPM will reach a decision within 30 days.
Except in certain circumstances, you will have to exhaust whatever appeal process your insurance company provides before you can ask OPM for External Review. If you are denied emergency services or if your doctor has determined that the denial of care would seriously jeopardize your life or jeopardize your ability to regain maximum function, you may be able to request External Review without first exhausting your insurance company's appeal process. In that case, OPM generally will make a decision within 72 hours.
MSP Program External Review National Healthcare Operations U.S. Office of Personnel Management 1900 E Street, NW Washington, DC 20415
You may appoint a representative to handle all matters related to your request for External Review by completing the Authorized Representative Form. The patient and their authorized representative must together sign and submit a single Authorized Representative Form. If a legal representative will complete the Authorized Representative Form on behalf of the patient, the legal representative must also provide proof of his or her legal representation (for example, a power of attorney instrument or proof of guardianship).