G.E.H.A Appeal Process and Disputed Claims FAQs

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1. What types of decisions can be appealed?
   Decisions related to claim denials, adverse benefit determinations and prior authorizations can be appealed.
2. What is the G.E.H.A appeal process?
   If you disagree with a G.E.H.A decision, you can appeal through the following steps:
   
   • 1st level: Initial appeal
     The member may appeal to G.E.H.A within six months of the decision. This can be done by mail, online or fax. If G.E.H.A upholds the decision, you may request reconsideration.
   • 2nd level: Reconsideration
     G.E.H.A reviews all information, consulting a health care professional if needed. If you still disagree with the decision, you may have the Office of Personnel Management (OPM) review your claim.
   • OPM review
     
     • Request OPM review within specified timeframes.
     • OPM provides a final decision within 60 days.
3. How do I submit an appeal to G.E.H.A?
   
   • Appeals can be submitted by mail to:
     G.E.H.A Post-Service Appeals
     P.O. Box 21324
     Eagan, MN 55121
   • For pre-service appeals send your request to:
     G.E.H.A
     P.O. Box 400046
     San Antonio, TX 78229
   • You may access the downloadable appeals forms by clicking the following link: geha.com/Appeals
   • You may also submit your appeals by fax or email at the following:
     
     • Fax: 1-866-963-0156
     • Email for medical appeals: gehaappeal@geha.com
     • Email for dental appeals: gehadentalappeals@geha.com
4. What information do I need to include in my appeal request?
   Include your name, member ID, date of birth, plan name, date of service, claim control number, total billed amount, provider name and a description of the dispute. Attach supporting documents such as physicians' letters, operative reports, bills, medical records and Explanation of Benefits (EOB) forms.
5. Can someone else submit an appeal on my behalf?
   Yes, someone else can submit an appeal on your behalf if they include the Designation of Authorized Representative form with the appeal request.
6. What is the timeline for G.E.H.A to review my appeal?
   G.E.H.A typically reviews post-service appeals within 30 days of receiving the request. For pre-service appeals, the timeline may vary.
7. How will I be notified of the decision on my appeal?
   You will be notified of the decision by mail or through the MyG.E.H.A member portal, depending on how you submitted your appeal. You can also opt to receive the decision via email.
8. What should I do if my appeal is denied?
   If your appeal is denied, you may request a second-level appeal or seek external review options as outlined in the denial notice. You may also appeal directly to OPM.
9. How can I check the status of my appeal?
   You can check the status of your appeal through MyG.E.H.A member portal or by contacting G.E.H.A customer service at 1-800-821-6136.
10. What resources are available to help me with the appeal process?
    G.E.H.A provides resources such as customer service support at 1-800-821-6136, and forms to help members with the appeal process in our online Resource Center.
11. What is the role of OPM in the appeal process?
    OPM reviews disputed claim requests and uses the information collected from you and G.E.H.A to decide whether the decision is correct. OPM will send you a final decision or notify you of the status of their review within 60 days.
12. What is the final recourse if I disagree with OPM's decision?
    If you disagree with OPM's decision, your only recourse is to file a lawsuit against OPM in federal court. You must file the suit by December 31 of the third year after the year in which you received the disputed services, drugs or supplies.
13. How can I request copies of the materials used to make a decision regarding my appeal?
    Members can request copies of the materials used in the decision-making process by completing the appropriate form available on the G.E.H.A website. The form can be accessed directly at geha.com/Appeals
14. Is the G.E.H.A website mobile-friendly?
    Yes, the G.E.H.A website is mobile-friendly and can be viewed easily on smartphones and other mobile devices.