Information on the Appeals Process for Disputed Claims under the Federal Employees Health Benefits Program

HRD-78-16: Published: Nov 22, 1977. Publicly Released: Nov 22, 1977.

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The Federal Employees Health Benefits program provides health insurance coverage for about 3.3 million enrollees (Government employees and annuitants) and over 6.4 million dependents. The health insurance plans review health benefits claims to determine if they are payable under their contracts with the Civil Service Commission (CSC). Federal regulations require the CSC to notify the enrollee and the health insurance plan of its finding within 30 days after it receives all information it requested to aid in reviewing the case.

A review of a random sample of disputed claims under the Government-wide plans fund that CSC met the Federal timeliness criterion in less than 30 percent of the cases. Of the claims reviewed under the Employee Organization Plans and Comprehensive Medical Plans, 80 percent and 85 percent, respectively, of the claims to CSC were resolved within the established time frames. For the first 3 quarters of 1977, the disputed claims rate (the number of claims appealed to CSC per 100,000 enrollees) was: 128 for the Government-wide plans (41 for Aetna and 151 for Blue Cross and Blue Shield), 30 for the Employee Organization Plans, and 17 for the Comprehensive Medical Plans. During the first 9 months of 1977, the monthly totals of claims onhand in the Government-wide Plans Division ranged from 948 in June to 1,501 in February. Annual salary costs for the claims appeal process were estimated at $639.000.

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