This guide outlines the appeal process for members enrolled in the Compass Rose Health Plan:
- Standard Option
- High Option
If you are enrolled in Compass Rose Medicare Advantage or Medicare Prescription Drug Plan (PDP) EGWP please refer to your Evidence of Coverage, which describes the Medicare appeals process separately.
For explanations of key terms used throughout this guide — such as types of appeals — please refer to the Terms and Definitions section at the end of this page.
Member Rights
If we deny a claim or coverage requested by you or your provider, you may request an appeal through our disputed claims process. Refer to the information below for details on how to submit your appeal, including required forms, important addresses, and deadlines.
The disputed claims appeal process, including your rights, can also be found in Sections 3 and 8 of our FEHB Plan brochure at compassrosebenefits.com/brochure.
Important Tips
Accessing Your Information
You can check the status of prior authorizations and view your claims by logging in to your myCompass account online and going to UMR or Optum Rx® at member.compassrosebenefits.com.
Consult Your Healthcare Provider Throughout the Appeal Process
If a prior authorization is denied, you and your provider will receive a denial letter from the appropriate source: UMR (for medical denials), Optum Rx (for pharmacy denials), or the Office of Personnel Management (OPM) (for an OPM appeal). If a post-service medical request is denied, refer to your Explanation of Benefits (EOB) or denial letter.
The denial letter or EOB will include the reason for denial and instructions for submitting an appeal for your specific situation. Your provider can help determine whether appealing the denial is appropriate or if an alternative treatment may be more suitable.
We recommend that you stay in contact with your provider throughout your appeal. Most providers’ offices have designated staff who are skilled at navigating these processes.
If a prescription is denied at the pharmacy, the rejection will include a message explaining the reason, which the pharmacy should communicate to you. If the pharmacy is unable to explain or fix the rejection, or if you have questions, call Optum Rx at 800-557-5785.
Different Processes for UMR, Optum Rx, and OPM
With few exceptions, you must first appeal a denied coverage request or claim directly with UMR (for medical denials) or Optum Rx (for pharmacy denials), before you may appeal to OPM. While these processes are similar, they are not identical. Required forms, addresses, and contact information are different.
Disputed Claims Appeal Processes
- 1st Level Appeal Process for Medical Denials (UMR)
- 1st Level Appeal Process for Pharmacy Denials (Optum Rx)
- 2nd Level OPM Appeal Process (Both Medical and Pharmacy Denials)
You must submit a 1st level appeal request to UMR within 6 months (180 calendar days) of the initial decision. For questions, please call UMR at 888-438-9135. Your appeal must include the following:
- A written appeal request – This should include a statement explaining why you believe the initial decision was incorrect. State whether your request is standard or urgent (please refer to definitions).
- Disputed Claim Form – Your written request and statement may be included on this form or attached to it. The form is available at compassrosebenefits.com/disputedclaim.
- Authorization of Representative (AOR) Form – Required if someone other than you, the member, is submitting the appeal. In urgent cases, a healthcare professional with knowledge of your medical condition may act as your representative without your express consent.
- Supporting documentation – This may include medical records, physician letters, bills, and/or explanation of benefits.
In addition, you and/or your provider have the right to request the information reviewed to make the initial decision — free-of-charge. Refer to your denial letter or EOB for information on making this request.
UMR will provide a determination within 30 days following receipt of all requested information, or within 72 hours for urgent requests. The determination will be mailed to you, your provider, and/or the facility. You may provide an email address within your appeal to have the determination emailed to you.
You must have a denied prior authorization before you may submit a 1st level appeal to Optum Rx.
You must submit a 1st level appeal request to Optum Rx within 6 months (180 calendar days) of the date on the denial letter you received from Optum Rx. For questions, please call Optum Rx at 888-403-3398.
Electronic prior authorization (ePA) is the preferred method for submitting appeals to Optum Rx. The ePA system is available to all prescribers. If you or your prescriber choose not to submit your appeal via the ePA system, your appeal should include the following:
- A written appeal request – This should include a statement or comments explaining why you believe the initial decision was incorrect. State whether your request is standard or urgent (please refer to definitions).
- Authorization of Representative (AOR) Form – This form should be included if anyone other than you or your prescriber is making the appeal request.
- Supporting documentation – This may include medical records, provider letters, or any other documents relevant to the appeal.
In addition, you may request a copy of the drug coverage policy, actual benefit provision, guideline, protocol, or other information used to make the initial decision — free of charge. Refer to your denial letter for information on making this request.
Optum Rx will provide a written determination within 30 calendar days following receipt of your appeal, or within 72 hours for urgent requests.
With few exceptions, you must first appeal a denied coverage request or claim directly with UMR (for medical denials) or Optum Rx (for pharmacy denials), before you may appeal to OPM.
If you would like to file an appeal with OPM, you must submit the appeal request no later than 90 days after the 1st level appeal was upheld. Your appeal must include the following:
- A written appeal request – This should include a statement explaining why you believe the initial decision was incorrect. State whether your request is standard or urgent (please refer to definitions).
- Supporting documentation – This may include medical records, explanation of benefits, physician letters, or copies of all communication sent to us and to you about this coverage request or claim.
- Contact information – Provide your daytime phone number and the best time to call. If you would like OPM’s decision to be sent to you via email, also provide your email address.
Mail your request to:
United States Office of Personnel Management
Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 2
1900 E Street, NW
Washington, DC 20415-3620
If your request is urgent you may call OPM at 202-606-3818.
OPM will provide a determination or notify you of the status of the review within 60 days. If you need urgent care, OPM will expedite your review if notified in your request.
If you disagree with OPM’s decision, you have the right to file a lawsuit against OPM no later than December 31 of the third year after the year in which you were denied prior approval or received the disputed service.
