If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. You or your provider must send the information so that we receive it within 60 days of our request. In the case of a post-service claim, we have 30 days from the date we receive your request to:ī) Write to you and maintain our denial orĬ) Ask you or your provider for more information. You may respond to that new evidence or rationale at the OPM review stage described in Step 3. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. 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.
#BCBS TIMELY FILING FOR APPEALS FREE#
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. You must:Ī) Write to us within 6 months from the date of our decision andī) 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 or the Specialty Drug Pharmacy Program) andĬ) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure andĭ) Include copies of documents that support your claim, such as physicians’ letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms. We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.Īsk us in writing to reconsider our initial decision. The review will not be conducted by the same person, or his/her subordinate, who made the initial decision. Our reconsideration will not take into account the initial decision.
#BCBS TIMELY FILING FOR APPEALS PROFESSIONAL#
When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.
Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. To make your request, please call us at the customer service telephone number on the back of your FEP Blue Focus ID card, or 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, or the Specialty Drug Pharmacy Program). For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7, and 8 of this brochure, please call your Plan’s customer service representative at the telephone number found on your identification card, plan brochure, or plan website ( To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim.
Office of Personnel Management (OPM) if we do not follow required claims processes. In Section 3, If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, drugs, or supplies that must have precertification (such as inpatient hospital admissions) or prior approval from the Plan. Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs, or supplies have already been provided).
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