Fighting a denied FEHB claim: the deadlines

Read the denial properly first

Most denials are not refusals of cover. They are administrative: a coding error, a missing referral, a service billed under the wrong date, an out-of-network provider inside an in-network facility.

Before writing anything, call the carrier and ask precisely why the claim was denied, and ask for the specific brochure provision they relied on. Ask your provider's billing office to check the coding at the same time. A fair share of denials disappear at this stage, and it costs a phone call.

If it survives that, the formal process begins, and it is set by regulation rather than by the carrier.

Step one: the carrier

Ask the carrier in writing to reconsider. Section 8 of your plan brochure gives the address and the rules.

• Deadline: six months from the date of the carrier's decision.
• Say why the decision was wrong, citing specific benefit provisions in the brochure. Fairness arguments carry no weight; brochure language does.
• Attach the evidence: the explanation of benefits, physician letters, operative reports, medical records and bills.
• If the carrier asks for more information, you or your provider normally have 60 days to supply it.
• Keep copies of everything, including the envelope's postmark.

Step two: OPM

If the carrier upholds the denial, you can ask OPM to review it. This is a genuine second look by the regulator, not a rubber stamp.

Write to OPM within whichever applies:

• 90 days after the date of the carrier's letter upholding its decision; or
• 120 days after you first wrote to the carrier, if they did not respond in some way within 30 days; or
• 120 days after the carrier asked for additional information, if no decision followed.

Send OPM the whole file: your statement citing brochure provisions, the supporting documents, copies of every letter in both directions, and a daytime phone number. OPM generally aims to decide within 60 days, and there is no further administrative appeal after it.

The deadline that never moves

If OPM upholds the denial, the only remaining route is a lawsuit against OPM in federal court, and you must have completed both earlier steps first.

The filing deadline is December 31 of the third year after the year in which you received the service, or in which precertification was denied. Plan brochures describe this as the one deadline that cannot be extended for any reason.

The court reviews the record that was in front of OPM, which is the strongest practical argument for putting every document in at the OPM stage rather than holding anything back.

If the condition is urgent

Where a delay could cause permanent harm or death, do not use the written timetable. Call the customer service number on your card, say plainly that it is urgent care, and ask for an expedited review. The carrier either expedites it or notifies OPM so the appeal can be reviewed quickly.

Do the same for a denied prior authorisation on treatment that is already scheduled.

What makes an appeal work

• Quote the brochure. Name the section and the sentence that entitles you to the benefit.
• Get the doctor to write the clinical reasoning, including why alternatives were unsuitable. A letter of medical necessity does more than any argument you can make yourself.
• Fix the administrative cause first, because a rebilled claim beats a won appeal every time.
• Keep a dated log of every call, name and reference number.
• Diary the deadlines the day the denial arrives. The six months and the 90 days are the whole game.

Choosing a plan with this in mind is easier than appealing later, and Section 8 is one of the parts worth reading before you enrol.

Common questions