Manage Claims & Records
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Dispute a Claim
There are times when you may not agree with the outcome of a pre-service or post-service claim. When this occurs, it is important that you know how file a dispute with the local Plan. The following types of disputes are available to you based on the type of claim being reviewed. You may also call the customer service number on the back of your ID card for additional information.
The first type of dispute available is a dispute of a pre-service claim denial. A pre-service claim is one that requires you or your provider to contact the local Plan to receive precertification for inpatient stays, or prior approval for other services where failure to obtain precertification or prior approval results in a reduction or denial of benefits. Sometimes, these claims can be considered urgent which require an expedited review.
If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of Other services, you may request a review by following the procedures listed below. Note that these procedures apply to requests for reconsideration of concurrent care claims as well. (If you have already received the service, supply, or treatment, then your claim is a post-service claim and you must follow the entire disputed claims process detailed in Section 8).
Download a Summary of the Disputed Claims Process
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:
- Precertify your inpatient admission or, if applicable, approve your request for prior approval for the service, drug or supply; or
- Write to you and maintain our denial; or
- Ask you or your provider for more information.
You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
To file an appeal with OPM
After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of the brochure.
Note: If you are enrolled in our Medicare PDP EGWP and do not agree with our benefit coverage decision, you have the right to appeal. See below for information about the PDP EGWP appeal process.