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Opm1840 (U.S. Office of Personnel Management)

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OPM Form 1840
January 2014
OMB Control Number 3206-0263
United States
Office of
Personnel Management
The Federal Government’s Human Resources Agency
Multi-State Plan Program
External Review Intake Form
Instructions
If you are enrolled in a Multi-State Plan (MSP) option and your claim has been denied by your
insurance company, you may use this form to ask the U.S. Office of Personnel Management (OPM)
to independently review that denial. This process is called External Review and is free of charge to
all enrollees.
Upon request, OPM will review whether your insurance company’s denial was justified by
examining the terms of coverage and the specific circumstances surrounding the denial. If medical
expertise is needed for review of a denial, OPM will seek the opinion of a contracted Independent
Review Organization (IRO). In most cases, OPM will communicate a decision within 30 days.
Except in certain circumstances, you will have to exhaust whatever appeal process your insurance
company provides before you can ask OPM for External Review. If your insurance company has not
responded to your request for an appeal generally within 30 days, or if you are denied emergency
services, or if your doctor has determined that the denial of care would seriously jeopardize your life
or jeopardize your ability to regain maximum function, you may be able to request External Review
without first exhausting your insurance company’s appeal process. In that case, OPM generally will
communicate a decision within 72 hours.
To file a request for External Review
1) Complete this External Review Intake Form and, if applicable, the Authorized
Representative Form (see below for more information about authorized representatives).
2) Submit them to OPM via email at mspp@opm.gov or via fax at (202) 606-0033, or mail
them to OPM at:
MSP Program External Review
National Healthcare Operations
U.S. Office of Personnel Management
1900 E Street, NW
Washington, DC 20415
3) You may call OPM toll free at (855) 318-0714 if you need help with your request for
External Review.
OPM Form 1840
January 2014
Multi-State Plan Program
External Review Intake Form Page 2
The following documents and information will help you complete the External Review Intake Form:
The letter from your insurance company stating that the company has denied your appeal.
This may not be required if you are requesting External Review for emergency services or if
your doctor has determined that the denial of care would seriously jeopardize your life or
jeopardize your ability to regain maximum function.
Identification number and plan name located on insurance identification card.
Physician or other health care provider’s contact information, including name, phone number,
and address (address is optional).
Any “explanation of benefits” (EOB) you may have received from your insurance company or
other medical documents related to the denial you are appealing.
You may be asked submit copies of these documents. When OPM has accepted your request for
external review, you will be notified that you will have twenty (20) days to submit any relevant
information that you believe supports your claim. OPM will consider that information together with
other information it receives from your insurance company and other sources, and this will be the
complete record upon which your claim will be decided.
Authorized Representative:
You may appoint a representative to handle all matters related to your request for External
Review by completing the Authorized Representative Form. The form is available from the
MSP website at http://www.opm.gov/healthcare-insurance/multi-state-plan-program/external-
review. The patient and the patient’s authorized representative must together sign and submit
a single Authorized Representative Form. If a legal representative other than the parent of a
minor will complete the Authorized Representative Form on behalf of the patient, the legal
representative must also provide proof of his or her legal representation (for example, a power
of attorney instrument or proof of guardianship).
Multi-State Plan Program
External Review Intake Form Page 3
________
________
Case Background Questions
1. Is this claim about health care you have already received, or is it about denial of requested pre-
authorization?
Service Already Received
Pre-authorization Requested
2. Are you currently admitted to a hospital or treatment facility and will you be required to leave due to your
denied claim?
Yes No
3. Has your doctor or other health care provider determined that your life will be at risk if you do not receive
this treatment in the next 30 days?
Yes No
4. Has your doctor or other health care provider determined that, if you wait 30 days for care, you m
ight never
fully recover?
Yes No
5. Have you filed an appeal with your insurance company?
Yes No
If yes, date of appeal to insurance company: Month: ________ Day: ____ Year:
Additional Details or Comments:
6. If you answered Yes to Question 5, have you received a letter from your insurance company denying your
appeal?
Yes No
If yes, date of appeal denial: Month: _______ Day: _____Year:
Additional Details or Comments:
OPM Form 1840
January 2014
Multi-State Plan Program
External Review Intake Form Page 4
Patient Information
1. Are you the patient whose claim was denied, or are you the patient’s authorized representative?
Patient
Authorized Representative. OPM will recognize an authorized representative if the patient and
his or her authorized representative have completed and submitted the External Review
Authorized Representative Form. The External Review Authorized Representative Form is
available from the MSP website at http://www.opm.gov/healthcare-insurance/multi-state-plan-
program/external-review.
2. Patient Relationship to Primary Insured (pick one).
Self Spouse
Dependent child under age 26
3. Patient Name:
Title: ____ First ________________ Middle____________ Last _________________________
Suffix ________
4. Patient Date of Birth:
Month: _________ Day: ____ Year: ______
5. Patient Contact Information:
Street Address 1: ___________________________________________________________________
Street Address 2: ______________________________________________________________
_____
City: ____________________________________________________________
_________________
State: ___________________ Zip Code: _______________________________________________
Email Address: _______________________________________________________________
______
Primary Phone: _______________________________________________________________
_____
I grant OPM permission to leave voice mail at the primary phone number above.
Secondary Phone:
______________________________________________________________
_____
I grant OPM permission to leave voice mail at the secondary phone number above.
Select one:
I prefer to communicate with OPM by U.S. Mail.
I prefer to communicate with OPM by email.
OPM Form 1840
January 2014
Multi-State Plan Program
External Review Intake Form Page 5
Health Insurance Information
1. Patient’s Health Insurance Member ID: _______________________________________________
2. Group Number: _________________________________________________________________
3. Patient’s Coverage State: __________________________________________________________
4. Insurance Company: _____________________________________________________________
5. Plan Name: _____________________________________________________________________
6. Primary Insured Full Name:
Title:
____ First _____________ Middle____________ Last _______________ Suffix ________
OPM Form 1840
January 2014
Multi-State Plan Program
External Review Intake Form Page 6
Health Care Provider Information
1. Health Care Provider or Facility Providing Treatment:
Facility Name:
_______________________________________________________________
Health Care Provider Name: ____________________________________________________
Title: ____ ______________
__________ ______________________ ____ First Middle Last Suffix
2. Health Care Provider or Facility Contact Information
Street Address 1:
__________________________________________________________
__
Street Address 2: __________________________________________________________
__
City: _________________________________________________________
_____________
State: ___________________________ Zip Code: _________________________________
Email Address: ___________________________________________________________
___
Office Phone: __________________________________________________________
_____
I grant OPM permission to communicate with my provider by leaving a leave voice mail at the
office phone number above and by mail and email.
OPM Form 1840
January 2014
Multi-State Plan Program
External Review Intake Form Page 7
Claim Information
1. Insurance Claim Number as listed on communication received from your insurance company:
2. Dates of Service:
Month: ________ ____ ____ Day: Year:
Month: ________
________
________
Day:
____ ____
____ ____
Year:
Month: Day: Year:
Month: Day: ____ Year: ____
3. Date Pre-authorization was requested by health care provider, if any:
Month: ________ Day: ____ Year: ____
4. Scheduled Dates of Service, if any, for which pre-authorization was sought:
Month: ________ Day: ____ Year: ____
Month:
________ ____ __ Day: Year: __
Month: ________ Day: __
__ Year: ____
Month: ________ Day: ____ Year: ____
5. Describe the basis for your External Review request:
I authorize OPM and its contracted Independent Review Organization to conduct medical review,
and I release any appropriate medical records for use by OPM to conduct external review of my claim.
OPM Form 1840
January 2014
Multi-State Plan Program
External Review Intake Form Page 8
Privacy Act Statement
In order to conduct an external review of your denied claim, the U.S. Office of Personnel Management (OPM)
requires you to submit this form. Provision of this information is voluntary, but if you omit information that is
necessary to decide your external review it is possible that your external review may not be conducted or may
be decided adversely.
OPM will use your information to determine whether you are eligible for external review, to conduct your
external review, to provide you or your insurer with a record of the external review, and for general
management of the external review system, including OPM's tracking and reporting on the external review
system. Other possible routine uses of your records include the following:
Disclosure to agency contractors, such as Independent Review Organizations, for the purpose of
conducting external review;
Responses to congressional inquiries initiated by you;
Investigations of potential violations of law, and judicial or administrative proceedings to which the
Federal Government is a party (the information may be provided to another agency, a court, an
administrative body, or to the Department of Justice, when the information is arguably relevant to the
proceeding);
Investigations of data breaches and responses to data breaches;
Disclosure to the National Archives and Records Administration (NARA) or the General Services
Administration (GSA) for records management purposes;
Disclosure to program and policy staff within OPM for statistical and analytical studies or to assist in
formulating health program changes; and
Disclosure to researchers inside and outside of the Federal Government, approved in advance by OPM
on the basis of demonstrated aptitude and a written research plan, conducting research on insurance
trends and topical issues.
OPM has the authority to administer the Multi-State Plan Program under section 1334 of the Affordable Care
Act (42 U.S.C. 18054).
Your Social Security Number (SSN) may be disclosed to OPM on some of the documents that you, your
health care provider, or your insurance plan may submit as part of an appeal to OPM. OPM will send a copy of
any information you send to OPM to the health insurance issuer that is involved in the relevant dispute. This
may include documents containing your SSN. OPM may need your SSN to identify your unique records as
authorized by Executive Order 9397. Although disclosure of your SSN is not mandatory, your failure to
disclose it when requested by OPM may prevent or delay the review.
Public Burden Statement
We estimate this form takes an average of 60 minutes to complete, including the time for reviewing
instructions, getting the needed data, and reviewing the completed form. Send comments regarding our
estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of
Personnel Management, National Healthcare Operations, 1900 E Street, NW, Washington, DC 20415-3430.
The OMB Number 3206-0263 is valid. OPM may not collect this information, and you are not required to
respond, unless this number is displayed.
OPM Form 1840
January 2014
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