Model Notice

OMB Control Number 3206-xxxx

Model Notice of Final Internal Adverse Benefit Determination –Revised as of [Insert date]

Date of Notice
Name of Plan
Address

Telephone/Fax
Website/Email Address

This document contains important information that you should retain for your records.
This document serves as notice of a final internal adverse benefit determination. We have declined to
provide benefits, in whole or in part, for the requested treatment or service described below. If you think
this determination was made in error, you may have the right to appeal (see the back of this page for
information about your appeal rights).
Internal Appeal Case Details:
Patient Name:
ID Number:
Address: (street, county, state, zip)
Claim #:

Date of Service:

Provider:
Reason for Upholding Denial (in whole or in part):
Amt.
Charged

Allowed
Amt.

Other
Insurance

Deductible

Co-pay

Coinsurance

Other Amts.
Not
Covered

Amt. Paid

YTD Credit toward Deductible:

YTD Credit toward Out-of-Pocket Maximum:

Description of Service:

Denial Codes:

[If denial is not related to a specific claim, only name and ID number need to be included in the box.
The reason for the denial would need to be clear in the narrative below.]
Background Information: Describe facts of the case including type of appeal and date appeal filed.

Final Internal Adverse Benefit Determination: State that adverse benefit determination has been
upheld. List all documents and statements that were reviewed to make this final internal adverse benefit
determination.

Findings: Discuss the reason or reasons for the final internal adverse benefit determination.
[Insert language assistance disclosure here, if applicable.
SPANISH (Español): Para obtener asistencia en Espanol, llame al [insert telephone number].

TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [insert telephone number].

CHINESE [Insert Chinese characters]

NAVAJO (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ [insert telephone number].

OPM Form 1842

What if I need help understanding this
denial?
Contact [Plan name, contact info] if you need
assistance understanding this notice or our
decision to deny you a service or coverage.
What if I don’t agree with this decision?
You are entitled to request an independent,
external review of our decision. Contact the
U.S. Office of Personnel Management (OPM)
toll free at 1-855-318-0714 with any questions
about your right to request external review of
this decision. Information is also available on
the web at http://www.opm.gov/healthcare­
insurance/multi-state-plan-program/external­
review/. You may also contact OPM at
[email protected] or via postal mail at:
MSP Program External Review
National Healthcare Operations
U.S. Office of Personnel Management

1900 E Street, NW

Washington, DC 20415

Who may file a request for external review?
You or someone you name to act for you (your
authorized representative) may file a request
for external review. You may authorize
someone to file on your behalf by completing
an Authorized Representative Form.
Can I provide additional information about
my claim?
Yes. After you have filed your request for
external review, you will receive instructions
on how to supply additional information.
Can I request copies of information relevant
to my claim?
Yes. You may request copies (free of charge)
by contacting [Plan name, contact info].

What happens next?
If you file a request for external review, OPM
will review our decision. If your claim was
denied as not medically necessary, OPM will
seek the binding opinion of an independent
Please see the section “Other resources to help
review organization. If your claim was denied
you” on this page if you need help filing a
based on coverage under your plan, OPM will
request for external review.
render a binding determination. If either the
independent review organization or OPM
What if my situation is urgent?
decides to overturn our decision, we will
All requests for external review will be handled
provide coverage or payment for your health
as quickly as possible. However, if your
care item or service.
situation is urgent, your request will be handled
within 72 hours of its receipt. Generally, an
Other resources to help you:
urgent situation is one that concerns an
For questions about your rights, this notice, or
admission, availability of care, continued stay,
for assistance, you can contact OPM toll free at
or health care service for which you have
1-855-318-0714. You can also learn more at
received emergency services, but have not been
http://www.opm.gov/healthcare­
discharged. A situation is also urgent if the
insurance/multi-state-plan-program/external­
standard External Review time frame would
review/. Additionally, a [consumer assistance
seriously jeopardize your life, health, or ability
program, ombudsman’s office, or consumer
to regain maximum function. You may request
complaints department] can help you file your
an expedited external review by contacting
appeal. Contact [name of program/office] at
OPM via toll free phone, email, or postal mail
[contact info].
as noted above.

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 5 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-XXXX is valid. OPM may not collect this information, and you are
not required to respond, unless this number is displayed.