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  • FEHB Claims Information

    Filing a claim for covered services

    Section 7 of your Plan brochure explains how to file a claim with us and explains four different claim categories: urgent care claims; concurrent care claims; pre-service claims, prior approval, or required referral; and post-service claims.

    In most cases, In-network providers and facilities will file claims for you while Out-of-network providers and facilities may ask that you pay up front or bill you directly. In those cases where you have paid a claim directly, you can submit a request for reimbursement.

    Physicians must submit their claims to us using the form CMS-1500, Health Insurance Claim Form. Hospitals or other medical facilities use the UB-04 Claim Form.

    Claims should be submitted as soon as possible for prompt processing and payment. At the very latest, claims must be submitted by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

    For claims questions or assistance, contact us at 1-671-647-3526. We're available 24 hours a day, 7 days a week.


    The disputed claim process

    Section 8 of your Plan brochure explains your rights to ask us to reconsider our claim decision and how to seek review by the U.S. Office of Personnel Management (OPM) of our reconsideration decision for your claim.

    Immediate Claims Appeals


    Full and fair review


    Avoiding conflicts of interest

    Note: The deadlines found in Section 8 of the plan brochure still apply to your claim, but these deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

    PLEASE REMEMBER THAT WE CANNOT DECIDE PLAN ELIGIBILITY ISSUES. FOR EXAMPLE, WE CANNOT DETERMINE WHETHER YOU OR A DEPENDENT IS COVERED UNDER THIS PLAN. YOU MUST RAISE ELIGIBILITY ISSUES WITH YOUR EMPLOYING OFFICE.



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