Sections 3 and 7 of your Plan brochure explain how to file a claim with us. Section 8 of your Plan brochure explains your rights to ask us to reconsider our claim decision and how to appeal to the U.S. Office of Personnel Management (OPM) for further review of your claim.
Filing a claim or appeal
Sections 3 and 7 of your Plan brochure explain how to file a claim and the timeframes the Health Plan must follow. The appeal process begins as soon as we receive a claim or appeal. If additional information is needed to make a determination, the Health Plan may request an extension (including a request for additional documentation). In such cases, the timeframe for making the determination will be delayed. If the Health Plain fails to adhere to these timeframes, you or your representative may immediately appeal to OPM as explained below.
The deadlines found in Section 8 of the Plan brochure apply to your claim, but these may be extended if you are unable to meet the deadline due to reasons beyond your control.
Full and fair review
You or your authorized representative have the right to ask us to reconsider our claim decision as described in Section 8 of the Plan brochure. To help you prepare your reconsideration request, you may arrange for us to review a copy of all relevant materials and Plan documents relating to your claim, including those that involve any expert reviews of your claim.
You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions. (Click here for the Designation of Personal Representative form.) For an urgent claim review, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your expressed consent.
To make your request, please contact our Public Relations Department by writing:
APWU Health Plan
Attention: Public Relations Department
6514 Meadowridge Road
Suite 195
Elkridge, MD 21075
Or calling:
1-800-222-2798
We are required to provide you with any new or additional evidence or rationale considered for our claims decisions. This information will be provided to you in advance of the date required by the timeframes outlined in your Plan brochure.
Our reconsideration will consider all comments, documents, records, and other information relating to the claim, regardless of whether such information was submitted or considered in the initial benefit determination.
When our initial decision is based (in whole or in part) on a medical judgment (e.g., 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.
If we do not substantially comply with these requirements, you may be able to immediately appeal to OPM, as explained below.
Immediate appeals
Our claims and appeals process, set forth in your Plan brochure, must comply with rules set forth under the Patient Protection and Affordable Care Act. If you believe that we have violated our claims or appeals procedures or that our procedures are deficient, you may immediately appeal to OPM.
However, if OPM finds that we are in “substantial compliance” with these rules, OPM may reject your immediate appeal. We will be in “substantial compliance” if our failure or violation is:
- Minor
- Non-prejudicial
- Attributable to good cause or matters beyond our control
- In the context of an ongoing good-faith exchange of information and
- Not part of a pattern or practice of non-compliance
You are entitled, upon written request, to an explanation of our basis for asserting that our procedures are substantially complaint. You may contact APWU Health Plan or UnitedHealthcare to request an explanation:
High Option:
APWU Health Plan
P.O. Box 8660
Elkridge, MD 21075
Consumer Driven Option:
UnitedHealthcare Appeals
P.O. Box 740816
Atlanta, GA 30374-0816
If OPM rejects your request for immediate review because we met the standard, you maintain the right to resubmit and pursue your claims and appeal through our claims and appeals process, which is set forth in your Plan brochure.
You may send an appeal to OPM:
Federal Employee Health Benefits Members
United States Office of Personnel Management
Healthcare and Insurance
Federal Employees Insurance Operation
FEHB2
1900 E Street, NW
Washington, DC 20415-3620
Postal Service Health Benefits Members
United States Office of Personnel Management
Health and Insurance
Postal Service Insurance Operations
1900 E Street, NW
Washington, DC 20415
If you want OPM to review more than one claim, you must clearly identify which documents apply to each claim.
If anyone other than yourself wishes to file a disputed claim on your behalf, that representative must include a copy of your specific written consent with the review request. However, for urgent claim reviews, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your expressed consent.
Avoiding conflicts of interest
The Health Plan’s reconsideration decision will not take into account the initial decision. The review will not be conducted by the same person or their subordinate who made the initial decision.
We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters regarding any individual (such as a claims adjudicator or medical expert) based on the likelihood that the individual will support the denial of benefits.
If we do not substantially comply with these requirements, you may be able to immediately appeal to OPM, as explained above.
Notice requirements
The Secretary of Health and Human Services has identified counties where at least 10% of the population is literate only in certain non-English languages. The non-English languages meeting this threshold in certain counties are Spanish, Chinese, Navajo, and Tagalog. If you live in one of these counties, we will provide language assistance in the applicable non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.
Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable) and a statement describing the availability, upon request, of the diagnosis and procedure codes and its corresponding meaning, and the treatment code and its corresponding meaning.