Civil Service Needs To Improve Claims Review Process Under the Federal Employee Health Benefits Program

In a review of the Civil Service Commission's (CSC) administration of the claims review process under the Federal Employees Health Benefits (FEHB) Program, an examination was made of: (1) a random sample of 62 closed disputed claim files from a March and April 1977 listing and an additional 42 files from cases closed during 4 days in October 1977; (2) all disputed claim files closed during December 1975 to April 1977 with required reports and records and, additionally, all disputed claim files from January to April 1977 with or without reports and records; and (3) all disputed claim files closed for December 1975 to May 1977 for the comprehensive plans (Aetna and Blue Cross and Blue Shield). In addition, a medical advisor reviewed 120 disputed claims files and the medical records for 55 of those cases.