| 1 |
No |
$0 |
$0 |
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We recommend that OPM immediately implement internal controls, including written policies and procedures, over the disputed claims process to fully define what constitutes a timely review in the context of 5 CFR Section 890.105, including but not limited to: - policies/procedures to govern the 90-day window allotted for OPM to review disputed claims; - policies/procedures to govern how OPM will address disputed claims appealed to them when the carrier reviewed the disputed claim outside the allotted timeframe and/or the FEHBP member's window to appeal expired (either at the carrier level [FEHBP Benefit Brochures, Section 3 and Section 8, Step 1 and 2] or OPM's level [FEHBP Benefit Brochures, Section 8, Step 3 and 4]); and - roles and responsibilities by position title of OPM personnel tasked with duties during the disputed claims process.
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| 2 |
No |
$0 |
$0 |
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We recommend that 5 CFR Section 890.107 be revised to align the start of FEHBP members' due process rights on the date of OPM's decision on the appeal and not the date on which the service was provided.
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| 3 |
No |
$0 |
$0 |
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We recommend that OPM implement written policies and procedures to address the use of additional information letters in the disputed claims process.
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| 4 |
No |
$0 |
$0 |
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We recommend that OPM implement policies and procedures to standardize the review of disputed claims, provide the policies and procedures to applicable OPM personnel, and implement a plan to review and update the policies and procedures regularly.
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| 6 |
No |
$0 |
$0 |
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We recommend that OPM implement a disputed claims process training program for new and current employees to ensure all personnel involved in the disputed claims review, regardless of assigned FEHB Group, are reviewing disputed claims timely and consistently.
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| 5 |
No |
$0 |
$0 |
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We recommend that OPM immediately implement written policies and procedures for the administration and use of FDC to ensure: - All FDC users are tracking disputed claim cases in the system consistently. - Disputed claim cases are consistently opened and closed in FDC among all users. - Disputed claim cases remain open in FDC during the 30-day FEHBP member response window, and OPM's 90-day review time frame includes the FEHBP member additional information letter process in cases where the FEHBP member responds timely. - The date of the FEHBP member additional information letter and the FEHBP member response date (if applicable) are made reportable fields in FDC. - FDC stores sufficient evidence to prove the FEHBP member provided new information after OPM made its decision, which warrants the reopening of the case. - All data components, including the medical codes (Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), etc.), are populated in FDC. - A process is established to assess FDC data trends, issues, and errors, so that corrective action can be implemented timely.
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| 8 |
No |
$0 |
$0 |
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We recommend that OPM update Section 8, Part 4 of the FEHBP benefit brochures to align with 5 CFR Section 890.105(e)(4), 48 CFR Section 1652.204-72(e)(4), and the FEHBP carrier Contract language Section 2.8(e)(4).
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| 7 |
No |
$0 |
$0 |
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We recommend that OPM implement a disputed claims quality assurance program to ensure that the disputed claims data is regularly reviewed for: - Consistent and timely logging and addressing of FEHBP member correspondence. - The identification of concerning trends with providers, procedures, prescriptions, etc. - Consistent reviews of like-kind claims. - OPM's adherence to the implemented policies and procedures. - Consistent handling of IMR reviews, especially in cases where the carrier provided at least one IMR itself. - Prompt identification and correction of human errors.
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| 9 |
No |
$0 |
$0 |
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We recommend that OPM implement internal controls to ensure that FOIA/PA requests can be met within the statutory deadlines.
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| 10 |
No |
$0 |
$0 |
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We recommend that OPM implement an internal control process to monitor Privacy Act requirements, as they relate to the Disputed Claims process, so that SORNs and other Privacy Act requirements are fulfilled in a timely manner.
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| 11 |
No |
$0 |
$0 |
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We recommend that OPM implement sufficient controls, including written policies and procedures, to ensure that FEHBP members' identities are verified and disputed claims records are not disclosed without consent as specified in the Privacy Act.
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| 12 |
No |
$0 |
$0 |
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We recommend that OPM evaluate the disputed claims data that relate to the decommissioned HITS and ensure that applicable paper files and electronic files are stored per the terms of 36 CRF, Chapter XII, Subchapter B, Records Management and OPM's RMP for the applicable disposition schedule.
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| 13 |
No |
$0 |
$0 |
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We recommend that OPM update the record retention period, ensuring that it provides sufficient time for the processing and resolution of a disputed claim.
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| 14 |
No |
$0 |
$0 |
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We recommend that OPM catalog the disputed claims cases where the same Y codes were applied to unique cases, and that OPM develop a unique record identifier for cases with the same Y code so that they can be clearly differentiated until the record retention requirements have expired.
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| 15 |
No |
$0 |
$0 |
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|
We recommend that OPM develop written policies and procedures that define the role of the Y code in the disputed claims process and the specific case data to be utilized by applicable OPM personnel to identify unique disputed claims cases.
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