Section 8. The disputed claims process

Step Description
1 Ask us in writing to reconsider our initial decision. You must:
  • Write to us within 6 months from the date of our decision; and

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  • Send your request to us at: SAMBA, 11301 Old Georgetown Road, Rockville, MD 20852-2800; and

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  • Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

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  • Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.
2 We have 30 days from the date we receive your request to:
  • Pay the claim or approve your request for coverage; or

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  • Write to you and maintain our denial - go to step 4; or

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  • Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request--go to step 3.
3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have.

We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:
  • 90 days after the date of our letter upholding our initial decision; or

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  • 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or

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  • 120 days after we asked for additional information.
Write to OPM at: United States Office of Personnel Management, Insurance Services Programs, Health Insurance Group II, 1900 E Street, NW, Washington, DC 20415-3620.

Send OPM the following information:
  • A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

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  • Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

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  • Copies of all letters you sent to us about the claim;

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  • Copies of all letters we sent to you about the claim; and

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  • Your daytime phone number and the best time to call.
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
  • We haven't responded yet to your initial request for care or preauthorization/prior approval, then call us at 1-800/638-6589 or 301/984-1440 (for TDD, use 301/984-4155) and we will expedite our review; or

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  • We denied your initial request for care or preauthorization/prior approval, then:
    • If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

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    • You may call OPM's Health Insurance Group II at 202/606-3818 between 8 a.m. and 5 p.m. eastern time.

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