FEHB / OPMPayer appeals · U.S. Office of Personnel Management (OPM)

How to appeal an FEHB denial (carrier, then OPM)

Federal Employees Health Benefits plans have a distinctive two-step appeal: you go back to the carrier first, and if it holds the denial, you ask OPM — the federal personnel agency — to review it.

An FEHB denial is appealed under 5 CFR 890.105: first you ask the carrier to reconsider, and if the carrier affirms the denial (or fails to respond in time), you ask the U.S. Office of Personnel Management to review the claim. OPM’s review is the independent step. Most appealable FEHB denials are medical-necessity and coverage decisions tied to the plan’s brochure.

How appeals work at FEHB (Federal Employees Health Benefits)

FEHB appeals run under 5 CFR 890.105. First, submit the claim to the carrier and, if it’s denied, ask the carrier in writing to reconsider; the carrier generally has 30 days to respond. If the carrier affirms the denial — or fails to respond as required — you may ask OPM to review the claim, generally within 90 days after the carrier’s affirmation (or within 120 days if the carrier didn’t respond). OPM’s determination is the independent review. The plan’s brochure is the governing coverage document.

What FEHB (Federal Employees Health Benefits) commonly denies

  • Medical necessity against the plan brochure’s coverage terms.
  • Prior authorization or coverage criteria not documented.
  • A service treated as not covered under the brochure.
  • Coding or claim-submission issues, corrected with the carrier.

Is a FEHB (Federal Employees Health Benefits) denial worth appealing?

Often worth appealing

Usually worth appealing medical-necessity and coverage denials: ask the carrier to reconsider first, mapping the record to the plan brochure’s terms, and if the carrier affirms, ask OPM to review within the deadline. OPM’s independent review is the lever that distinguishes FEHB — use it. Watch the 90-day window after the carrier’s affirmation.

How to appeal a FEHB (Federal Employees Health Benefits) denial

  1. 1

    Ask the carrier to reconsider

    Submit a written reconsideration request to the carrier and map the record to the plan brochure’s coverage terms.

  2. 2

    Then ask OPM to review

    If the carrier affirms the denial, request OPM review — generally within 90 days of the affirmation (120 days if the carrier didn’t respond).

  3. 3

    Use the brochure as the standard

    The plan brochure is the governing coverage document; quote its terms and show how the record meets them.

FEHB (Federal Employees Health Benefits) — frequently asked

Who decides my FEHB appeal?
First the carrier, on reconsideration. If the carrier affirms the denial, the U.S. Office of Personnel Management reviews the claim — that OPM review is the independent step under 5 CFR 890.105.
How long do I have to ask OPM to review?
Generally within 90 days after the carrier’s notice affirming the denial — or within 120 days of your reconsideration request if the carrier failed to respond.

Related guides

CO-50 · medical necessityMedical-necessity letterCO-197 · auth absent

Sources

Appeal timeframes and venues are summarized from the federal ERISA/ACA and Medicare Advantage frameworks and vary by plan; payer-specific deadlines and addresses are on your denial notice. Medicare Advantage figures are from KFF's 2024 analysis. This is general information, not legal or coverage advice — confirm the deadline and process on the notice and the plan documents.

When the appeal has to be written, and cited

Upload the denied EOB and Merits returns a complete, citation-verified appeal letter — the clinical argument, the payer's own coverage criteria, and your federal appeal rights — in about a minute.

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