Non Urgent Pre-service
and Post-service Claims
1. Ask us in writing to reconsider our initial decision.
You must :
a. Write to us within six months from the date of
our decision; and
b. Send your request to us at the address shown on
your explanation of benefits (EOB) form for the local
Plan that processed the claim (or, for prescription
drug benefits, our Retail Pharmacy Program, Mail
Service Pharmacy Program, or the Specialty Drug
Pharmacy Program); and
c. Include a statement about why you believe our
initial decision was wrong, based on specific benefit
provisions in the brochure; and
d. Include copies of documents that support your claim,
such as physicians’ letters, operative reports, bills,
medical records, and EOB forms.
We will provide you, free of charge and in a timely
manner, with any new or additional evidence considered,
relied upon, or generated by us or at our direction in
connection with your claim and any new rationale for our
claim decision. We will provide you with this information
sufficiently in advance of the date that we are required to
provide you with our reconsideration decision to allow you
a reasonable opportunity to respond to us before that date.
However, our failure to provide you with new evidence
or rationale in sufficient time to allow you to respond
timely shall not invalidate our decision on reconsideration.
You may respond to that new evidence or rationale at the
Office of Personnel Management (OPM) review stage.
2. In the case of a pre-service claim and subject to a
request for additional information, we have 30 days
from the date we receive your written request for
reconsideration to:
a. Precertify your hospital stay or, if applicable, approve
your request for prior approval for the service, drug or
supply; or
b. Write to you and maintain our denial; or
c. Ask you or your provider for more information.
3. In the case of a post-service claim, we have 30 days
from the date we receive your request to:
a. Pay the claim; or
b. Write to you and maintain our denial; or
c. Ask you or your provider for more information.
For both non-urgent pre-service and post-service claims,
you or your provider must send the information so that we
receive it within 60 days of our request. We will then make
our decision with the new information or, if the information
was not received, with the information we already have
within 30 more calendar days. We will write to you with
our decision.
Urgent Care Claims
If you have an urgent care claim (i.e., when waiting for
your medical care or treatment could seriously jeopardize
your life, health, or ability to regain maximum function,
or in the opinion of a physician with knowledge of your
medical condition, would subject you to severe pain that
cannot be adequately managed without the requested
care or treatment), we will expedite our review of the
claim and notify you of our decision within 72 hours after
you have followed step one noted above. To request an
expedited handling of your reconsideration dispute when
this definition is met, you can call the health plan customer
service number on the back of your ID card.
We will expedite the review process, which allows
oral or written requests for appeals and the exchange
of information by telephone, electronic mail, facsimile,
or other expeditious methods.
If you fail to provide sufficient information for us to make
a decision on your expedited request, we will contact
you within 24 hours after we receive your reconsideration
request. We will allow you up to 48 hours from the receipt
of the request to provide the necessary information.
If your case warrants expedited handling, we will make
our decision on the claim within 48 hours of (1) the time
we received the additional information or (2) the end of
the 72-hour time frame, whichever is earlier.
INTERNAL APPEALS