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External Review
If you were enrolled in a Multi-State Plan (MSP) option in 2018 and your claim or request for health care was denied by your insurance company, you may ask the U.S. Office of Personnel Management (OPM) to independently review that decision. This process is called External Review and is free to all enrollees. Note, you must submit an external review request by June 2022.
OPM will review whether your insurance company’s denial was justified by examining the terms of coverage and the specific circumstances surrounding the denial. If medical expertise is needed for review of a denial, OPM will seek the opinion of a contracted Independent Review Organization (IRO). In most cases, OPM will reach a decision within 30 days.
Except in certain circumstances, you will have to exhaust whatever appeal process your insurance company provides before you can ask OPM for External Review. If you are denied emergency services or if your doctor has determined that the denial of care would seriously jeopardize your life or jeopardize your ability to regain maximum function, you may be able to request External Review without first exhausting your insurance company's appeal process. In that case, OPM generally will make a decision within 72 hours.
To file a request for External Review:
- Download and complete the External Review Intake Form and, if applicable, the Authorized Representative Form (see below for more information about authorized representatives).
- Submit them to OPM via email at mspp@opm.gov, via fax at (202) 606-0033, or mail them to:
Multi-State Plan (MSP) Program External Review
National Healthcare Operations
U.S. Office of Personnel Management
1900 E Street, NW
Washington, DC 20415 - You may call OPM toll free at (855) 318-0714 if you need help with your request for External Review.
Please gather the following prior to completing the External Review Intake Form:
- The letter from your insurance company stating that the company has denied your appeal. This may not be required if you are requesting External Review for emergency services or if your doctor has determined that the denial of care would seriously jeopardize your life or jeopardize your ability to regain maximum function.
- Insurance identification card, including identification number and plan name.
- Physician or other health care provider's contact information, including name, phone number, and address (address is optional).
- Any "explanation of benefits" (EOB) you may have received from your insurance company or other medical documents related to the denial you are appealing.
- Dates of service or scheduled dates of service.
Authorized Representative:
You may appoint a representative to handle all matters related to your request for External Review by completing the Authorized Representative Form. The patient and their authorized representative must together sign and submit a single Authorized Representative Form. If a legal representative will complete the Authorized Representative Form on behalf of the patient, the legal representative must also provide proof of his or her legal representation (for example, a power of attorney instrument or proof of guardianship).
