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Code of Federal Regulations (Last Updated: November 8, 2024) |
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Title 45 - Public Welfare |
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Subtitle B - Regulations Relating to Public Welfare |
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Chapter VIII - Office of Personnel Management |
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Part 800 - Multi-State Plan Program |
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Subpart F - Appeals by Enrollees of Denials of Claims for Payment or Service |
§ 800.503 - External review.
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§ 800.503 External review.
(a) External review by OPM. OPM will conduct external review of adverse benefit determinations using a process similar to OPM review of disputed claims under 5 CFR 890.105(e), subject to the standards and timeframes set forth in 45 CFR 147.136(d).
(b) Notice. Notices to MSP enrollees regarding external review under paragraph (a) of this section must comply with 45 CFR 147.136(e), and are subject to review and approval by OPM.
(c) Issuer obligation. An MSP issuer must pay a claim or provide a health-related service or supply pursuant to OPM's final decision or the final decision of an independent review organization without delay, regardless of whether the plan or issuer intends to seek judicial review of the external review decision and unless or until there is a judicial decision otherwise.