[Federal Register Volume 60, Number 60 (Wednesday, March 29, 1995)]
[Rules and Regulations]
[Pages 16037-16039]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-7793]



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 Rules and Regulations
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  Federal Register / Vol. 60, No. 60 / Wednesday, March 29, 1995 / 
Rules and Regulations  
[[Page 16037]]

OFFICE OF PERSONNEL MANAGEMENT

5 CFR Part 890

RIN 3206-AF18


Federal Employees Health Benefits Program: Filing Claims; 
Disputed Claims Procedures and Court Actions

AGENCY: Office of Personnel Management.

ACTION: Interim regulations with request for comments.

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SUMMARY: The Office of Personnel Management (OPM) is issuing interim 
regulations to revise the requirement that legal actions to recover on 
a claim under the Federal Employees Health Benefits (FEHB) Program 
should be brought against the health benefits carrier rather than OPM, 
and to clarify the procedures for filing claims for payment or service 
under the FEHB Program. The purpose of these interim regulations is to 
clarify that if a covered individual chooses to bring legal action 
pertaining to a denial of an FEHB benefit, such legal action should be 
brought against OPM, and to clarify the administrative review process 
that must precede legal action in the courts.

DATES: These interim regulations are effective March 29, 1995. Comments 
must be received on or before May 30, 1995.

ADDRESSES: Send written comments to Lucretia F. Myers, Assistant 
Director for Insurance Programs, Retirement and Insurance Service, 
Office of Personnel Management, P.O. Box 57, Washington, DC 20044; or 
delivery to OPM, Room 3451, 1900 E Street NW., Washington, DC; or FAX 
to (202) 606-0633.

FOR FURTHER INFORMATION CONTACT:
Margaret Sears, (202) 606-0004.

SUPPLEMENTARY INFORMATION: Historically, OPM has required that covered 
individuals who want to bring suit because an FEHB carrier has denied 
their claim for health benefits must sue the carrier, not OPM. These 
interim regulations provide that legal actions arising out of a denial 
of FEHB benefits should be brought against OPM rather than the FEHB 
carrier that made the initial denial decision. Because OPM has the 
authority under the FEHB law to order the carrier to pay the claim, OPM 
has determined it is appropriate under current statute for the covered 
individual to bring suit against OPM if OPM declines to order the 
carrier to pay the claim. The interim regulations also clarify the 
process and circumstances for bringing legal actions under the FEHB 
Program. They clearly state that the administrative review process set 
forth in 5 CFR 890.105 must be completed before suit is brought. To 
further clarify the purpose and intent of these regulations, we have 
changed the title of the regulation at 890.107 from ``Legal actions'' 
to ``Court Review.''
    The legislative history of Sec. 8902(j), title 5, United States 
Code, shows that Congress intended OPM (at that time the Civil Service 
Commission) to provide an administrative appeal process, binding upon 
the carriers, that would save covered individuals the expense and delay 
of being forced into the courts to recover on meritorious claims for 
benefits. Based upon this directive and its central role in the 
administration of the FEBH Program, OPM established a detailed 
administrative review process for benefits claims leading to a final 
decision on such claims by OPM. It is OPM's view that this 
administrative review process must be followed before legal action is 
pursued in the courts. Further, the matter to be reviewed by a court 
upon appeal is the OPM decision affirming the carrier's denial of 
benefits, with the court's review being limited to an examination of 
OPM's administrative decision to deny the claim for payment or 
services.
    Health insurance contracts under the FEHB Program are Federal 
contracts under 5 U.S.C., chapter 89. Accordingly, legal actions 
concerning disputes arising or relating to those contracts are 
controlled by Federal, rather than State law. Congress, in the FEHB 
Act, mandated Federal uniformity for all matters that relate to (1) the 
nature or extent of coverage; (2) benefits; and (3) payment of benefits 
under the FEHB Program. By statute, all health insurance contracts 
require the carrier to agree to pay or provide a health service or 
supply in an individual case if OPM finds that the covered individual 
is entitled to the benefit under the terms of the contract. Congress 
also directed OPM to take a central role in determining whether a 
health service or supply should be provided in individual cases to 
covered individuals and, if it should be provided, to require carriers 
to pay for such health service or supply. These interim regulations 
reaffirm the principle of uniformity in the FEHB Program by providing 
that in judicial disputes regarding the denial of a health benefits 
claim, review is to be limited to the record that was before OPM and 
that was the basis of the OPM decision to disallow the benefit. In the 
event that an appropriate court concludes that benefits should have 
been awarded under the FEBH Act, the court possesses ample authority to 
require OPM to order that such payments be made to the covered 
individual from the carrier. These interim regulations clarify that OPM 
intends for its decision to be upheld unless the court concludes that 
the OPM decision affirming the carrier's denial of benefits was 
inconsistent with the standard for a final agency action under 
applicable Federal law.
    The administrative review process is set forth in 15 CFR 890.105, 
Filing claims for payment or service. Section 890.105 outlines the 
procedures for filing claims for payment or service when there is a 
disagreement over payment or service between the carrier and the 
covered individual. In addition, the regulations make minor changes in 
the time limits for carrier reconsideration and OPM review of claims in 
890.105 to make the language easier to read.

Waiver of Notice of Proposed Rulemaking

    Pursuant to section 553(b)(3)(B) of title 5 of the U.S. Code, I 
find that good cause exists for waiving the general notice of 
rulemaking because these interim regulations remove a restriction on 
the actions of Federal employees and annuitants.

Regulatory Flexibility Act

    I certify that this regulation will not have a significant economic 
impact on a substantial number of small entities because the 
regulations primarily affect [[Page 16038]] individuals enrolled under 
the Federal Employees Health Benefits Program.

List of Subjects in 5 CFR Part 890

    Administrative practice and procedure, Government employees Health 
facilities, Health insurance, Health professions, Hostages, Iraq, 
Kuwait, Lebanon, Reports and recordkeeping requirements, Retirement.

Office of Personnel Management.
James B. King,
Director.

    Accordingly, OPM is amending 5 CFR part 890 as follows:

PART 890--FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM

    1. The authority citation for part 890 continues to read as 
follows:

    Authority: 5 U.S.C. 8913; Sec. 890.803 also issued under 50 
U.S.C. 403p, 22 U.S.C. 4069c and 4069c-1; subpart L also issued 
under sec. 599C of Pub. L. 101-513, 104 Stat. 2064, as amended.

    2. In Sec. 890.101 paragraph (a) is amended by adding a definition 
of ``covered individual'' to read as follows:


Sec. 890.101  Definitions; time computations.

    (a) * * *
    Covered individual means an enrollee or a covered family member.
* * * * *
    3. Section 890.105 is revised to read as follows:


Sec. 890.105  Filing claims for payment or service.

    (a) General. Each health benefits carrier resolves claims filed 
under the plan. All health benefits claims must be submitted initially 
to the carrier of the claimant's health benefits plan. If the carrier 
denies a claim (or a portion of a claim), the covered individual may 
ask the carrier to reconsider its denial. If the carrier affirms its 
denial or fails to respond as required by paragraph (b) of this 
section, the covered individual may ask OPM to review the claim. A 
covered individual must exhaust both the carrier and OPM review 
processes specified in this section before seeking judicial review of 
the denied claim.
    (b) Time limits for reconsidering a claim. (1) The covered 
individual has 1 year from the date of the notice to the covered 
individual that a claim (or a portion of a claim) was denied by the 
carrier in which to submit a written request for reconsideration to the 
carrier.
    (2) The carrier has 30 days after the date of receipt of a timely-
filed request for reconsideration to:
    (i) Affirm the denial in writing to the covered individual;
    (ii) Pay the bill or provide the service; or
    (iii) Request from the covered individual or provider additional 
information needed to make a decision on the claim. The carrier must 
simultaneously notify the covered individual of the information 
requested if it requests additional information from a provider. The 
carrier has 30 days after the date the information is received to 
affirm the denial in writing to the covered individual or pay the bill 
or provide the service. The carrier must make its decision based on the 
evidence it has if the covered individual or provider does not respond 
within 60 days after the date of the carrier's notice requesting 
additional information. The carrier must then send written notice to 
the covered individual of its decision on the claim. The covered 
individual may request OPM review as provided in paragraph (b)(3) of 
this section if the carrier fails to act within 30 days after the 
covered individual's request for reconsideration or the carrier's 
receipt of additional information.
    (3) The covered individual may write to OPM and request that OPM 
review the carrier's decision if the carrier either affirms its denial 
of a claim or fails to respond to a covered individual's written 
request for reconsideration within 30 days after the date it receives 
the request or within 30 days after the date it receives the additional 
information requested. The covered individual must submit the request 
for OPM review within the time limit specified in paragraph (e)(1) of 
this section.
    (4) The carrier may extend the time limit for a covered 
individual's submission of additional information to the carrier when 
the covered individual shows he or she was not notified of the time 
limit or was prevented by circumstances beyond his or her control from 
submitting the additional information.
    (c) Information required to process requests for reconsideration. 
(1) The covered individual must put the request to the carrier to 
reconsider a claim in writing and give the reasons, in terms of 
applicable brochure provisions, that the denied claim should have been 
approved.
    (2) If the carrier needs additional information from the covered 
individual to make a decision, it must:
    (i) Specifically identify the information needed;
    (ii) State the reason the information is required to make a 
decision on the claim;
    (iii) Specify the time limit (60 days after the date of the 
carrier's request) for submitting the information; and
    (iv) State the consequences of failure to respond within the time 
limit specified, as set out in paragraph (b)(2) of this section.
    (d) Carrier determinations. The carrier must provide written notice 
to the covered individual of its determination. If the carrier affirms 
the initial denial, the notice must inform the covered individual of:
    (1) The specific and detailed reasons for the denial;
    (2) The covered individual's right to request a review by OPM; and
    (3) The requirement that requests for OPM review must be received 
within 90 days after the date of the carrier's denial notice and 
include a copy of the denial notice as well as documents to support the 
covered individual's position.
    (e) OPM review. (1) If the covered individual seeks further review 
of the denied claim, the covered individual must make a request to OPM 
to review the carrier's decision. Such a request to OPM must be made:
    (i) Within 90 days after the date of the carrier's notice to the 
covered individual that the denial was affirmed; or
    (ii) If the carrier fails to respond to the covered individual as 
provided in paragraph (b)(2) of this section, within 120 days after the 
date of the covered individual's timely request for reconsideration by 
the carrier; or
    (iii) Within 120 days after the date the carrier requests 
additional information from the covered individual, or the date the 
covered individual is notified that the carrier is requesting 
additional information from a provider. OPM may extend the time limit 
for a covered individual's request for OPM review when the covered 
individual shows he or she was not notified of the time limit or was 
prevented by circumstances beyond his or her control from submitting 
the request for OPM review within the time limit.
    (2) In reviewing a claim denied by the carrier, OPM may:
    (i) Request that the covered individual submit additional 
information;
    (ii) Obtain an advisory opinion from an independent physician;
    (iii) Obtain any other information as may in its judgment be 
required to make a determination; or
    (iv) Make its decision based solely on the information the covered 
individual provided with his or her request for review.
    (3) When OPM requests information from the carrier, the carrier 
must release the information within 30 days after the 
[[Page 16039]] date of OPM's written request unless a different time 
limit is specified by OPM in its request.

    (4) Within 90 days after receipt of the request for review, OPM 
will either:

    (i) Give a written notice of its decision to the covered individual 
and the carrier; or

    (ii) Notify the individual of the status of the review. If OPM does 
not receive requested evidence within 15 days after expiration of the 
applicable time limit in paragraph (e)(3) of this section, OPM may make 
its decision based solely on information available to it at that time 
and give a written notice of its decision to the covered individual and 
to the carrier.

    4. Section 890.107 is revised to read as follows:

Sec. 890.107  Court Review.

    (a) A suit to compel enrollment under Sec. 890.102 of this part 
must be brought against the employing office that made the enrollment 
decision.

    (b) A suit to review the legality of OPM's regulations under this 
part must be brought against the Office of Personnel Management.

    (c) Federal Employees Health Benefits (FEHB) carriers resolve FEHB 
claims under authority of State statute (chapter 89, title 5, United 
States Code). A covered individual may seek judicial review of OPM's 
final action on the denial of a health benefits claim. A legal action 
to review final action by OPM involving such denial of health benefits 
must be brought against OPM. The recovery in such a suit will be 
limited to the amount of benefits in dispute.

    (d) An action under paragraph (c) of this section to recover on a 
claim for health benefits:

    (1) May not be brought prior to exhaustion of the administrative 
remedies provided in Sec. 890.105;

    (2) May not be brought later than December 31 of the 3rd year after 
the year in which the care or service was provided; and

    (3) Will be limited to the record that was before OPM when it 
rendered its decision affirming the carrier's denial of benefits.

[FR Doc. 95-7793 Filed 3-28-95; 8:45 am]

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