FEHB disputed claims for behavioral health: deadlines, OPM review and consent

Who manages behavioral health in an FEHB plan?

Each FEHB carrier resolves claims under its own plan, and OPM reviews disputes. A carrier may use subcontractors, so a denial can come from a behavioral health vendor, but the brochure and the disputed claims rule still govern. The notice and the plan's brochure name who decided and where the reconsideration goes.

Familiar brands do not change the process. The Blue Cross and Blue Shield Service Benefit Plan works through local Blue plans, but its members dispute claims under Section 8 of its FEHB brochure, not a local commercial manual. That plan's 2026 brochure says postal employees and annuitants are no longer eligible for it, and OPM's call letter treats Postal Service Health Benefits as a separate program, so check which program the card names.

What are the FEHB deadlines?

The member has 6 months from the date of the denial notice to ask the plan in writing to reconsider. The plan then has 30 days to pay, affirm in writing or ask for more information. OPM review must be requested within 90 days of an affirmed denial, or within 120 days if the plan stays silent.

The 6 months can be extended when circumstances beyond the member's control prevented a timely request. If the plan asks for more information, the member or provider has 60 days; the plan then has 30 days to decide, and a plan that hears nothing decides on the evidence it has. OPM can extend its deadline when the member was not told of the limit or was prevented by circumstances beyond the member's control (5 CFR 890.105(e)(1)). ClaimParrot's appeal deadline calculator does not cover federal employee plans, so count from the notice by hand.

Who can file an FEHB disputed claim?

The covered individual can, and so can a person or entity with the covered individual's specific written consent to pursue payment of that disputed claim. Providers need that consent. For urgent care claims, two 2026 brochures say a healthcare professional who knows the condition can act as the authorized representative without express consent.

Both brochures say the member is the only person with a right to file a disputed claim with OPM, and that a provider acting as representative must include a copy of the specific written consent with the review request. We did not verify a separate contract dispute route for network providers, so check your agreement with the carrier.

How should you argue an FEHB reconsideration?

In terms of the brochure. The rule requires written reasons, based on applicable brochure provisions, why the claim should have been approved, and OPM decides whether the plan's decision was correct. Quote the brochure's benefit language for the level of care, then tie each dated record to that language.

When the first decision rests on medical judgment, both brochures say the plan consults a healthcare professional with appropriate training who was not involved in that decision. The rule has no pause for a peer-to-peer conversation, so if the plan offers one, do not let it run past the 6 months.

• Write within 6 months to the address the plan gives, usually the one on the explanation of benefits.
• State why the decision was wrong, citing specific benefit provisions in the brochure.
• Attach the evidence: physician letters, medical records, bills and the explanation of benefits.
• Watch for new evidence: both 2026 brochures we read promise any new evidence or rationale in time to respond before the plan decides, and you can also respond at OPM.

How are urgent FEHB claims handled?

The two 2026 brochures we read promise a decision within 72 hours after the reconsideration request, unless the plan asks for more information, and allow fast exchanges by phone or fax. The regulation sets no urgent timeframe, so the member's own brochure controls. Ask for simultaneous OPM review where the brochure offers it.

Both brochures define an urgent care claim as one where waiting could seriously jeopardize life, health or the ability to regain maximum function, or where a physician who knows the condition says it would cause severe pain that cannot be adequately managed without the treatment. Both treat a reduction or end of a pre-approved course of treatment, before the approved period or number of treatments ends, as an appealable decision, and promise time to appeal and get a decision before the cut takes effect.

A request to extend an ongoing course at least 24 hours before it expires, on a claim that is also urgent, is decided within 24 hours in both. Terms can differ by plan, so read the member's own Section 3 and Section 7. The expedited continued-stay appeal can start the letter once citations that do not apply to FEHB come out.

What happens at OPM review?

The member writes to OPM with a statement of why the decision was wrong under the brochure, the denial notice and supporting documents. OPM can ask for more information or an independent physician's advisory opinion. Within 90 days of receipt, the rule says OPM either decides or reports the review's status.

The two 2026 brochures we read say 60 days for that decision or status notice, so treat the rule's 90 days as the outer limit. Both also say a member may appeal directly to OPM if the plan does not follow required claims processes, and both name the OPM office and address in Section 8. OPM can reopen its review if evidence that was unavailable at the time of its decision arrives (5 CFR 890.105(e)(5)).

Can a member sue over an FEHB denial?

Yes, after finishing both the plan and OPM reviews, and only against OPM, not the carrier. The suit must be filed by December 31 of the third year after the year of the care. The court reviews the record that was before OPM, and recovery is limited to the benefits in dispute.

That limit on the record is the practical point (5 CFR 890.107(c), (d)): evidence left out of the OPM request may never reach a judge, so send OPM the full record rather than holding anything back.

Which clinical criteria do FEHB plans name?

OPM's rule names no clinical criteria; the test is the plan's brochure and contract. The two 2026 brochures we read name no LOCUS, InterQual, MCG or ASAM Criteria, so ask the plan which guideline it applied and ask for a copy. GEHA's brochure also points to medical and payment policies on its website.

Authorization rules sit in the brochure too. The Service Benefit Plan requires prior approval for ABA and its related services, and GEHA requires precertification for inpatient stays, residential treatment centers and intensive day treatment unless due to a medical emergency.

OPM's call letter for plan year 2026 tells carriers that limit behavioral benefits to document comparative analyses and make them available at OPM's direction, and the Service Benefit Plan brochure describes a yearly parity analysis. The disputed claims rule still asks for reasons in terms of the brochure, so build the request there.

How do you get the file from an FEHB plan?

The two 2026 brochures we read let the member review and copy, free of charge, all relevant materials and plan documents under the plan's control, including expert reviews. OPM's call letter told carriers to explain on their websites how and when members can get those materials. Ask in writing, early, and keep the response.

ClaimParrot's criteria request letter has no FEHB version and its citations do not fit, so cite the brochure's own language instead.

Where do you submit an FEHB reconsideration?

To the address the plan gives, usually on the explanation of benefits or the denial letter, following Section 8 of that year's brochure. OPM's call letter told carriers to offer several filing methods, such as secure email or fax, and a downloadable fact sheet. Requests to OPM go to the address in that same section.

Which denial codes come up on FEHB behavioral health claims?

Where a remittance or explanation of benefits carries standard claim adjustment reason codes, medical necessity (50) and authorization codes (39, 197, 198) usually lead to a reconsideration under the brochure's terms, frequency (151) and timely filing (29) need dated records, and provider codes (170, 185) need credentialing records.