OPM 1840 MSP Program External Review Case Intake Form

OMB Control Number 3206-0263

United States

Office of
Personnel Management
Tlte Federal Government's Human Resources Ag~ncy

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 Extemal 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 [email protected] or via fax at (202) 606-0033, or mail
·
them to OPM at:
MSP Program External Review
National Health care Operations
U.S. Office of Personnel Management
1900 E Street, NW
Washington, DC 20415
3) You may call OPM toll fi"ee at (855) 318-0714 if you need help with your request for
Extemal Review.
OPMForm 1840

Multi-State Plan Program
External Review Intake Form Page 2

The following docrnnents 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.
Member 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.

Please submit copies of any documents (see above in BOLD) you may want us to consider in making
our decision. Once OPM accepts your request for external review, we will notify you. You will have
twenty (20) days to submit any relevant information that you believe supports your claim. OPM will
consider that information together with information we receive from your insurance company and
other sources. We will base our decision on this complete record of information.

Authorized Representative:
•

You may appoint a representative to handle all matters related to your request for External
Review by completing the Authorized Representative Fmm. The form is available from the
MSP website at http://www.opm.gov/healthcare-insurance/multi-state-plan-program/externalreview. 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

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 Fonn is
available from the MSP website at http://www.opm.gov/healthcare-insurance/multi-state-planprogram/extemal-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:
StreclAdillessl: --------------------~------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 grru1t 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 cmmnunicate with OPM by email.

Multi-State Plan Program
External Review Intake Form Page 4

Case Background Questions
I. Is this claim about health care you have already received, or is it about denial of requested preauthorization?
_ _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 might 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: _ _

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:

Multi-State Plan Program
External Review Intake Form Page 5

Health Care Provider Information
I. Health Care Provider or Facility Providing Treatment:
FacilityName: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Health Care Provider Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
· Title:

First _ _ _ _ _ _ Middle_ _ _ _ Last _ _ _ _ _ _ _ __

2. Health Care Provider or Facility Contact Information

Street Address 1: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Street Address 2: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
City:
State: _ _ _ _ _ _ _ _ _ _ _ Zip Code:
Email Address:
Office Phone: _ _ _ _ _ _ _ _ _ _Fax Number: _ _ _ _ _ _ _ _ _ _ __
_ _ _ I grant OPM pennission to connnunicate with my provider by leaving a leave voice mail at
the office phone number above and by mail and email.

Health Insurance Information
Please refer to your Health Insurance member ID card to complete the section below.
1. Patient's Health Insurance Member ID:

3. Effective Date of Coverage: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
4. Patient's Coverage State:
5. h1surance Company: -------------------~------6. Plan Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
7. Primary h1sured Full Name: First _ _ _ _ _ _ Middle_ _ _ _ _ Last------,-------

Multi-State Plan Program
External Review Intake Form Page 6

Claim Information
Please use any Explanation of Benefit (EOB) form, denial letters to help complete the section
below.

1. fusurance Chum Number and/or Reference Number as listed on communication received fi-om your
insurance company: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

2. Dates of Service: Montb: _ _ 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: _ _

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.

Multi-State Plan Program
External Review Intake Form Page 7

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 fonn. Provision of this infonnation 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 detennine 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 oflaw, 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 infonnation 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 stndies or to assist in
fonnulating health program changes; and
Disclosure to researchers inside and outside of the Federal Government, approved in advance by OPM
on the basis of demonstrated aptitnde 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 pa1t 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 fonn, including suggestions for reducing completion time, to the Office of
Persmmel 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.