Does a FEHBA plan have policy language like an ERISA plan?
Yes. FEHBA Plans can be found here or requested through the subrogation vendor or insurance carrier.
Do I need to notify a FEHBA Plan when I make a claim for personal injuries against a third party?
The terms of a FEHBA Plan will articulate the responsibilities of the parties. Typically, the Plan requires cooperation and notification in circumstances where another party may become responsible for the medical benefits the Plan has already paid.
Here’s an example of relevant policy language:
- If you do seek damages for your illness or injury, you must tell us promptly that you have made a claim against another party for a condition that we have paid or may pay benefits for, you must seek recovery of our benefit payments and liabilities, and you must tell us about any recoveries you obtain, whether in or out of court.
- We may request that you sign a reimbursement agreement and/or assign to us (1) your right to bring an action or (2) your right to the proceeds of a claim for your illness or injury. We may delay processing of your claims until you provide the signed reimbursement agreement and/or assignment, and we may enforce our right of recovery by offsetting future benefits.
The review of the FEHBA Payment Summary to ensure there are no errors, duplicates, or unrelated treatment is included.
The Federal Employees Health Benefits Act (FEHBA) of 1959 (5 U.S.C. 8901 et seq.)
The Office of Personnel Management. This federal agency manages and directs the FEHBA program including the approval of Plan language and the negotiation of contract rates.
The governing document outlining the coverage, as well as the rights and responsibilities, agreed to by the plan holder and the beneficiary.
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