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DOCUMENT FESUML
042941 [ B33341561] !r+d~~/-2 2
Information on the Appeals Process for Disputed Claims under the
Federal Employees Health Benefits Program. HRD-78-16; B-164562.
November 22, 1977. 2 pp. + 2 appendices (11 pp. ).
Report to Rep. John E. Moss; Ly Elmer B. Staats, Comptroller
General.
issue Area: Health Programs (1200).
Contact: Human Resources Div.
Budget Function: Health: Health Care Services (551).
Organization Concerned: Civil Service Commission.
Congressional Relevance: Rep. John E. Moss.
Authority: Federal Employees Health Benefits Act of 1959 (5
U.S.C. 8901). P.L. 93-246. 5 C.F.R. 890.105.
The Federal Employees Health Benefits program provides
health insurance coverage for about 3.3 million enrollees
(Government employees and annuitants) and over 6.4 million
dependents. The health insurance plans review health benefits
claims to determine if they are payable under their contracts
with the Civil Service Commission (CSC). Federal regulations
require the CSC to notify the enrollee and the health insurance
plan of its finding within 30 days after it receives all
information it requested to aid in reviewing the case.
Findings/Conclusions: A review of a random sample of disputed
claims under the Government--wide plans found that CSC met the
Federal timeliness criterion in less than 30% of the cases. Of
the claims reviewed under the Employee Organization Plans and
Comprehensive Medical Plans, 80% and 85%, respectively, of the
claims to CSC were resolved within the established time frames.
For the first 3 quarters cf 1977, the disputed clains rate (the
number of claims appealed to CSC per 100,000 enrollees) was: 128
for tho Government-uide plans (41 for Aetna and 151 for Blue
Criss and Blue Shield), 30 for the Employee organization Plans,
aaid 17 for the Comprehensive Medical Plans. During the first 9
months of 1977, the monthly totals of claims onhand in the
G~vernrent-wide Plans Division ran%'ed from 948 in June to 1,501
in February. Annual salary costs for the claims appeal process
were estimated at $639.000. (Author/SW)](ViewImageLocal?handle=hein.gao/gaobaawid0001&div=1&collection=&method=preview&ext=.png&size=3)