Identification cards | We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider; or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, contact us as follows:
- High Option: Call us at 800-222-2798 (TTY 800-622-2511) or write to us at P.O. Box 1358, Glen Burnie, MD 21060-1358 or through our website at www.apwuhp.com. You may print or request an Identification Card via the Member Portal at www.myAPWUHP.com.
- Consumer Driven Option: Call UnitedHealthcare at 800-718-1299 or write to us at P.O. Box 740800, Atlanta, GA 30374-0800 or request replacement cards through the website at www.myuhc.com.
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Where you get covered care
| You can get care from any “covered provider” or “covered facility.” How much we pay – and you pay – depends on the type of covered provider or facility you use. If you use our preferred providers, you will pay less. |
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Balance Billing Protection | FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in-network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, coinsurance) contact your Carrier to enforce the terms of its provider contract. |
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| We provide benefits for the services of covered professional providers, as required by Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state's designation as a medically underserved area.
Covered professional providers are medical practitioners who perform covered services when acting within the scope of their license or certification under applicable state law and who furnish, bill, or are paid for their healthcare services in the normal course of business. Covered services must be provided in the state in which the practitioner is licensed or certified.
This plan recognizes that transgender, non-binary, and other gender diverse members require healthcare delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.
This plan provides Care Coordinators for complex conditions and can be reached at 800-582-1314 for Cigna and 800-718-1299 for UnitedHealthcare for assistance. |
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| Covered facilities include:
- Freestanding ambulatory facility: An out-of-hospital facility such as a medical, cancer, dialysis, or surgical center or clinic, and licensed outpatient facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations for treatment of substance use disorder treatment.
- Hospital
- An institution which is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations, or
- Any other institution which is operated pursuant to law, under the supervision of a staff of doctors and twenty-four hour a day nursing service, and which is primarily engaged in providing: a) general inpatient care and treatment of sick and injured persons through medical, diagnostic and major surgical facilities, all of which must be provided on its premises or under its control, or b) specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized provider of those facilities.
The term "hospital" shall not include a skilled nursing facility, a convalescent nursing home or institution or part thereof which 1) is used principally as a convalescent facility, rest facility, residential treatment center, nursing facility or facility for the aged; or 2) furnishes primarily domiciliary or custodial care, including training in the routines of daily living.
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| Specialty care: If you have a chronic or disabling condition and
- lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan, or
- lose access to your PPO specialist because we terminate our contract with your specialist for reasons other than cause,
You may be able to continue seeing your specialist and receiving any PPO benefits for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.
If you are pregnant and you lose access to your specialist based on the above circumstances, you can continue to see your specialist and your PPO benefits will continue until the end of your postpartum care, even if it is beyond the 90 days.
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- If you are hospitalized when your enrollment begins
| We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our High Option begins, call our Customer Service Department immediately at 800-222-2798. For the Consumer Driven Option, please call UnitedHealthcare at 800-718-1299. If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
- you are discharged, not merely moved to an alternative care center;
- the day your benefits from your former plan run out; or
- the 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment. |
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You need prior Plan approval for certain services | The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services, are detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services. In other words, a pre-service claim for benefits 1) requires precertification or prior approval and 2) will result in a reduction of benefits if you do not obtain precertification or prior approval.
You must get prior approval for certain services. Failure to do so will result in a minimum $500 penalty for inpatient hospital (High Option and Consumer Driven Option) or $100 for certain outpatient radiology/imaging procedures (for High Option only). |
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- Inpatient hospital admission, inpatient residential treatment center admission or skilled nursing facility admission
| Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we won’t change our decision on medical necessity.
In most cases, your physician or hospital will take care of requesting precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician or hospital whether or not they have contacted us. |
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| Warning | We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis. |
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| Exceptions | You do not need precertification in these cases: - You are admitted to a hospital outside the United States and Puerto Rico.
- You have another group health insurance policy that is the primary payor for the hospital stay.
- Medicare Part A is the primary payor for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payor and you do need precertification.
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| Some services require prior approval.
Under the High Option, call Cigna/CareAllies at 800-582-1314 if you need any of the services listed below:
- Applied Behavioral Analysis (ABA)
- Durable medical equipment such as wheelchairs, oxygen equipment and supplies, artificial limbs (prosthetic devices) and braces
- Gender affirming surgery
- Gene Therapy
- Genetic testing, including BRCA testing (see Definitions, Section 10, page 146)
- Home healthcare such as nursing visits, infusion therapy, growth hormone therapy (GHT), rehabilitative and habilitative therapy (speech therapy) and pulmonary rehabilitation programs
- Iatrogenic fertility preservation procedures
- Minimally invasive treatment of back and neck pain. This requirement applies to both the physician services and the facility. The following services require prior approval: epidural steroid injections, facet joint injections, sacroiliac joint injections.
- Organ transplantation - call before your first evaluation as a potential candidate
- Procedures which may be cosmetic in nature such as eyelid surgery (blepharoplasty), varicose vein surgery (sclerotherapy), or Botox injections for medical diagnosis
- Recognized surgery for morbid obesity (bariatric surgery) or for organic impotence
- Residential Treatment Center (RTC)
- Services and supplies which may be experimental/investigational
- Skilled Nursing Facilities (SNF)
- Prior approval for outpatient services at Veterans Administration facilities is not needed
Under the Consumer Driven Option, call UnitedHealthcare at 800-718-1299 if you need any of the services listed below:
- Air Ambulance - Non emergent
- Applied Behavioral Analysis (ABA)
- Bariatric surgery
- Clinical Trials
- Chemotherapy - outpatient
- Congenital Heart Disease
- Durable Medical Equipment (including Insulin pumps)
- Functional endoscopic sinus surgery
- Gender affirming surgery
- Genetic testing
- Home healthcare - nursing visits, home infusion therapy
- Hospice - inpatient
- Hysterectomy
- Iatrogenic fertility preservation procedures
- Organ transplantation
- Orthognathic surgery
- Potential cosmetic procedures
- Residential Treatment Center (RTC)
- Services and supplies which may be experimental/investigational
- Sinuplasty
- Skilled Nursing Facilities (SNF)
- Sleep apnea procedures and surgery
- Therapeutics (outpatient) dialysis, IV infusion, radiation oncology, intensity modulated radiation therapy, MR-guided focused ultrasound
- Prior approval is required for certain classes of drugs and coverage authorization is required for some medications. This authorization uses Plan rules based on FDA-approved prescribing and safety information, clinical guidelines, and uses that are considered reasonable, safe, and effective. For example, prescription drugs used for cosmetic purposes such as Retin A or Botox may not be covered. Other medications might be limited to a certain amount (such as quantity or dosage) within a specific time period, or require authorization to confirm clinical use based on FDA labeling. To inquire if your medication requires prior approval or authorization, call Express Scripts Customer Service at 800-841-2734 for the High Option (see Section 5(f), page 72), and Optum Rx at 800-718-1299 for the Consumer Driven Option (see Section 5(f), page 120).
- Prior approval is also required for mental health and substance use disorder benefits, inpatient, in-network or out-of-network. Prior approval is required for psychological and neuropsychological testing (CDHP Option only), Electroconvulsive therapy (CDHP Option only), Transcranial Magnetic Stimulation (TMS), and services such as partial or full day hospitalization or facility-based intensive outpatient treatment (Cigna Behavioral Health for the High Option and UHC Behavioral Health Solutions for the Consumer Driven Option). Under the High Option, call Cigna Behavioral Health at 800-582-1314. Under the Consumer Driven Option, call UHC Behavioral Health Solutions at 800-718-1299.
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How to request precertification for an admission or get prior authorization for Other services |
- High Option: First you, your representative, your physician, or your hospital must call Cigna/CareAllies at 800-582-1314 at least 2 business days before admission or services requiring prior authorization are rendered. For mental health and substance use disorder inpatient treatment, your physician or your hospital must call Cigna/CareAllies at 800-582-1314 at least 2 business days before admission or services requiring prior authorization. These numbers are available 24 hours every day.
- Consumer Driven Option: First you, your representative, your physician, or your hospital must call UnitedHealthcare at 800-718-1299 at least 2 business days before admission or services requiring prior authorization are rendered. For mental health and substance use disorder inpatient treatment, your doctor or your hospital must call UnitedHealthcare Behavioral Health Solutions at 800-718-1299 at least 2 business days before admission or services requiring prior authorization. These numbers are available 24 hours every day.
- If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone the above number at least 2 business days for the High Option and the Consumer Driven Option following the day of the emergency admission, even if you have been discharged from the hospital.
- Next, provide the following information:
- enrollee’s name and Plan identification number
- patient’s name, birth date, and phone number
- reason for hospitalization, proposed treatment, or surgery
- name and phone number of admitting physician
- name of hospital or facility; and
- number of days requested for hospital stay
- We will then tell the physician and/or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your physician, and the hospital.
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What happens when you do not follow the precertification rules |
- If no one contacts us, we will decide whether the hospital stay was medically necessary.
- If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty.
If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis for High Option and Consumer Driven Option out-of-network stays.
If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis for High Option and Consumer Driven Option out-of-network stays.
When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then:
- For the part of the admission that was medically necessary, we will pay inpatient benefits, but
- For the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits for High Option and Consumer Driven Option out-of-network services.
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- Radiology/imaging procedures precertification
| High Option: Radiology precertification is required prior to scheduling specific imaging procedures. We evaluate the medical necessity of your proposed procedure to ensure that the appropriate procedure is being requested for your condition. In most cases your physician will take care of the precertification. Because you are responsible for ensuring that precertification is done, you should ask your doctor to contact us.
The following outpatient radiology services require precertification:
- CT/CAT Scan – Computerized Axial Tomography
- MRI – Magnetic Resonance Imaging
- MRA – Magnetic Resonance Angiography
- PET – Positron Emission Tomography
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- How to precertify a radiology/imaging procedure
| For these outpatient studies, you, your representative or doctor must call Cigna/CareAllies before scheduling the procedure. The toll free number is 800-582-1314. - Provide the following information:
- patient’s name, Plan identification number, and birth date
- requested procedure and clinical support for request
- name and phone number of ordering provider
- name of requested imaging facility
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Warning
| We will reduce our benefits for these procedures by $100 if no one contacts us for precertification. If the procedure is not medically necessary, we will not pay any benefits. |
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Exceptions | You do not need precertification in these cases:
- You have another health insurance policy that is primary including Medicare Parts A&B or Part B Only
- The procedure is performed outside the United States or Puerto Rico
- You are an inpatient at a hospital
- The procedure is performed while in the Emergency Room
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| For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim.
If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.
If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information. |
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| If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.
If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.
We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.
You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-222-2798. You may also call FEHB at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-222-2798. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim). |
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Concurrent care claims | A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.
If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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- Emergency inpatient admission
| If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. If you do not telephone the Plan within two business days, penalties may apply - see Warning under Inpatient hospital admissions earlier in this Section and If your hospital stay needs to be extended below. |
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| You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.
Note: When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
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- If your hospital stay needs to be extended
| High Option: If your hospital stay – including for maternity care – needs to be extended, you, your representative, your physician or the hospital must ask us to approve the additional days by calling the precertification vendor Cigna/CareAllies at 800-582-1314. If you remain in the hospital beyond the number of days we approved and did not get the additional days precertified, then
- For the part of the admission that was medically necessary, we will pay inpatient benefits, but
- For the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.
Consumer Driven Option: If your hospital stay – including for maternity care – needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days by calling UnitedHealthcare at 800-718-1299. If you remain in the hospital beyond the number of days we approved and did not get the additional days precertified, then
- For the part of the admission that was medically necessary, we will pay inpatient benefits, but
- For the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits for out-of-network services only.
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- If your treatment needs to be extended
| If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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If you disagree with our pre-service decision | If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 800-841-2734 for the High Option and 800-718-1299 for the Consumer Driven Option.
If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8. |
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- To reconsider a non-urgent care claim
| Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.
In the case of a pre-service claim and that is subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to:
1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
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.
3. Write to you and maintain our denial. |
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- To reconsider an urgent care claim
| In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods. |
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- To file an appeal with OPM
| After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure. |
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