Filing claims for payment or service.

CFR · 2024-01-01 · US · Title 5

(a) (2) This section applies to covered individuals and to other individuals or entities who are acting on the behalf of a covered individual and who have the covered individual's specific written consent to pursue payment of the disputed claim. (b) (2) The carrier has 30 days after the date of receipt of a timely-filed request for reconsideration to: (i) Affirm the denial in writing to the covered individual; (ii) Pay the bill or provide the service; or (iii) Request from the covered individual or provider additional information needed to make a decision on the claim. The carrier must simultaneously notify the covered individual of the information requested if it requests additional information from a provider. The carrier has 30 days after the date the information is received to affirm the denial in writing to the covered individual or pay the bill or provide the service. The carrier must make its decision based on the evidence it has if the covered individual or provider does not respond within 60 days after the date of the carrier's notice requesting additional information. The carrier must then send written notice to the covered individual of its decision on the claim. The covered individual may request OPM review as provided in paragraph (b)(3) of this section if the carrier fails to act within the time limit set forth in this paragraph (b)(2)(iii). (3) The covered individual may write to OPM and request that OPM review the carrier's decision if the carrier either affir

official document · source cfr-2024 · id 5:§ 890.105