FEHB appeals

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 as described below. If your claim is in reference to a contraceptive, call Customer Care at 1-800-359-2002. To ask us in writing to reconsider our initial request, you must:

1. Write to us within six months from the date of our decision; and
2. Send your request to us at: Sharp Health Plan, Attention: Appeal/Grievance Department, 8520 Tech Way, Suite 200, San Diego, CA 92123-1450; and
3. Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in your Federal Employees Health Benefits (FEHB) Brochure; and
4. 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 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 timely respond 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 described in Step 4 of the disputed claims process detailed in Section 8 of your FEHB Brochure.

We have 30 days from the date we receive your written request for consideration to complete one of the following:

1. Pre-certify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. 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.
3. Write to you and maintain our denial.

If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us – if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

You may send an appeal to OPM at:

United States Office of Personnel Management, Healthcare and Insurance
Federal Employees Insurance Operations
Health Insurance 3
1900 E Street, NW
Washington, DC 20415-3630

Include the following information with your appeal:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in your FEHB Brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and EOB forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM's decision via email.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision or notify you of the status of OMP's review within 60 days. There are no other administrative appeals.

If you do not agree with OPM's decision, your only recourse is to file a lawsuit. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

If you have a serious or life-threatening condition (one that may cause permanent loss of bodily function or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 1-800-359-2002. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM at 1-202-606-0737 between 8 a.m. and 5 p.m. Eastern Time.