Appeals and Disputed Claims Processes
Federal Employees Health Benefits Program Appeal and Disputed Claims Processes
Follow the steps below if you disagree with our decision on your post service claim or pre-service precertification/prior approval denial request for services, drugs, or supplies.
Please refer to Section 3 of the Plan brochure for pre-service appeals and Section 8 for disputed claims.
How to file an appeal or disputed claim
How to file an appeal related to our claim procedures or appeals procedures
Our claims and appeals process, set forth in the Plan brochure, is required to 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. If OPM rejects your request for immediate review on the basis that we met the standard, you maintain the right to resubmit and pursue your claim and appeal through our claims and appeals process, set forth in the Plan brochure.
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 the Plan brochure please call your plan’s customer service representative at 1-202-833-4910.
You are entitled, upon written request, to an explanation of our basis for asserting that our procedures are substantially compliant. You may contact the Plan to request an explanation:
Foreign Service Benefit Plan
1620 L Street, NW, Suite 800
Washington, DC 20036-5629
Time periods for claims
Sections 3 and 7 of the Plan brochure explains how to file a claim with us. We are required to meet the timeframes for claims filed, listed in these sections or you may immediately appeal to OPM as explained above. Any time periods for benefit or appeal determinations in the brochure begin at the time a claim for benefits or appeal is filed in accordance with these claims procedures, without regard to whether we receive all information necessary to process a claim. If the information we need to make a decision on your claim is not included with your claim, we may request an extension including a request for the specific information. In such cases, the period for making the determination will be delayed.
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.
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 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. To make your request, please contact our Customer Service Department by writing to Foreign Service Benefit Plan, 1620 L Street, NW, Suite 800, Washington, DC 20036-5629 or through our secure Member Portal at myafspa.org (login to the Member Portal with your username and password), or by calling 1-202-833-4910 (Monday through Friday 8:30 AM–5:30 PM ET).
We are required to 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. We will also provide you, free of charge and in a timely manner, with any new rationale for our claim decision. We will provide this information sufficiently in advance of the date by which we are required to provide you with our reconsideration decision to allow you reasonable opportunity to respond prior to that date. We will identify for you the medical or vocational experts whose advice we obtained in connection with 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.
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 health care 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 above.
Avoiding conflicts of interest
Our reconsideration decision will not afford deference to the initial decision and will be conducted by a plan representative who is neither the individual who made the initial decision that is the subject of the reconsideration, nor the subordinate of that individual.
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.
If we do not substantially comply with these requirements, you may be able to immediately appeal to OPM as explained above.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). This is a brief description of the features of the Foreign Service Benefit Plan (FSBP). Before making a final decision, please read the Official Plan brochure. All benefits are subject to the definitions, limitations and exclusions set forth in the Official Plan brochure.
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