The Disputed Claims (Appeals) Process requires that you submit your appeal for pre or post services in writing and within six (6) months of the date on your decision letter. For your convenience, written appeals may be submitted using any of the following methods:
Western Health Advantage
ATT: Appeals & Grievances Department
2349 Gateway Oaks Drive, Suite 100 | Sacramento, CA 95833
Fax: 916.563.2207 | Email: appeal.grievance@westernhealth.com
Online Submission: Website Grievance Form
Within your written request, please include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in your FEHBP Brochure. Also include copies of documents that support your claim, such as a physician letter, operative reports, bills, medical records, and explanation of benefits (EOB) forms.
If we consider any new or additional information when reviewing your appeal, we will share it with you at no cost. We will provide this information as early as possible so you have a reasonable opportunity to review it and respond before we issue our appeal decision.
If we are unable to provide this information in advance, it will not affect the validity of our decision. In that case, you may submit your response to the Office of Personnel Management (OPM) if you request an OPM review of your appeal.
After we receive your written request for reconsideration, we will respond within 30 days. During this time, we will do one of the following:
- Approve your request, including pre-certification of a hospital stay or granting prior approval for a service, drug, or supply, when applicable;
- Ask you or your provider for additional information needed to complete our review; or
- Uphold our original decision and explain the reason in writing.
If we ask for more information, you or your provider must send it so that we receive it within 60 days of our request. Once we receive the information, we will issue a decision within 30 days.
If we do not receive the requested information within 60 days, we will make a decision within 30 days based on the information already available and notify you in writing.