American Foreign Service Protective Association

December 15, 2014Dear [redacted] , This is in response to your December letter regarding a complaint filed to the Revdex.com by our member, [redacted] (Revdex.com complaint ID [redacted] ), Here are our findings: In May of we received a claim submission from [redacted] consisting of a cover sheet dated May that listed seven claims including the two claims in question, for dates of service 8/14/and 8/31/Although the two claims are listed on the cover sheet, we have no record that they were included with his submissionWe processed the claims we received with his submission in accordance with our contract provisions.Subsequently, [redacted] did submit the two claims in question in October 2014, They were denied for timely filing, per the provision cited below, on 10/22/The Foreign Service Benefit Plan (FSBP) has a claim timely filing limitPage of our Brochure in Section 7, Filing a claim for covered services, states: “Deadline for filing your claim Send us all of the documents for your claim as soon as possibleYou must submit the claim within years from the date you incur the expenseIf you could not file on time because of Government administrative operations or legal incapacity, you must submit your claim as soon as reasonably possibleOnce we pay benefits, there is a three-year limitation on the reissuance of uncashed checks,” On November [redacted] emailed our Chief Executive Officer and our Vice President, Health Operations stating that he was unable to get an explanation as to why his claims were not processed and that he was not able to speak with a supervisor at the time of his callUpon review of [redacted] 's concerns, we determined that, although the claims were not submitted in his original correspondence of May 6, 2013, it was his intent to submit the two claims in question since they were listed on his cover sheet and considered that to be notice of claimTherefore, we waived our timely filing limit and paid the claims on 11/26/We notified [redacted] via email on 11/26/that the claims had been paidWe have conducted additional training with personnel involved with this claimPlease set us know if you have any questionsSincerely, Lesley FSupervisor, Health Operations

June 22, 2015Dear *** ***,This is in response to your letter dated June 2, 2015.We reviewed our processing of claim *** as well as the maternity care benefits in the Foreign Service Benefit Plan (FSBP) BrochureUnder the maternity care benefit on page of our
FSBP Brochure, we cover “Postnatal care." Postnatal care consists of medically necessary visits to a doctor following childbirthWe provide coverage for inpatient hospitals stays for childbirth (up to hours for a vaginal delivery and hours for a C-section.) We will cover an extended hospital stay if medically necessary.The service rendered was a week long stay, following childbirth, at a separate facility where new mothers can rest before taking on the full responsibility of caring for a newbornThese are not medically necessary services and are not covered by the Plan.All benefits are subject to the definitions, limitations and exclusions in the FSBP Brochure and are payable only when we determine they are medically necessaryThe Brochure also states, in the Introduction on page three: “This brochure is the official statement of benefitsNo oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure."On 11/25/we received an appeal from *** *** disputing the handling of claim ***A letter response was mailed to him on 12/22/upholding the original handing of the claim and advising him that if he did not agree, he had the right to request a review from the Office of Personnel Management (OPM)A copy of this letter is enclosed.Please let us know if you have any questions.Sincerely,
MsLeslie F

December 15, 2014Dear [redacted],
This is in response to your December 5 letter regarding a complaint filed to the Revdex.com by our member, [redacted] (Revdex.com complaint ID [redacted]),
Here are our findings:
In May of 2013 we received a...

claim submission from [redacted] consisting of a cover sheet dated May 6 2013 that listed seven claims including the two claims in question, for dates of service 8/14/12 and 8/31/12. Although the two claims are listed on the cover sheet, we have no record that they were included with his submission. We processed the claims we received with his submission in accordance with our contract provisions.Subsequently, [redacted] did submit the two claims in question in October 2014, They were denied for timely filing, per the provision cited below, on 10/22/2014.
The Foreign Service Benefit Plan (FSBP) has a claim timely filing limit. Page 89 of our 2014 Brochure in Section 7, Filing a claim for covered services, states:
“Deadline for filing your claim
Send us all of the documents for your claim as soon as possible. You must submit the claim within 2 years from the date you incur the expense. If you could not file on time because of Government administrative operations or legal incapacity, you must submit your claim as soon as reasonably possible. Once we pay benefits, there is a three-year limitation on the reissuance of uncashed checks,”
On November 14 [redacted] emailed our Chief Executive Officer and our Vice President, Health Operations stating that he was unable to get an explanation as to why his claims were not processed and that he was not able to speak with a supervisor at the time of his call.
Upon review of [redacted]'s concerns, we determined that, although the claims were not submitted in his original correspondence of May 6, 2013, it was his intent to submit the two claims in question since they were listed on his cover sheet and considered that to be notice of claim. Therefore, we waived our timely filing limit and paid the claims on 11/26/14. We notified [redacted] via email on 11/26/14 that the claims had been paid.
We have conducted additional training with personnel involved with this claim.
Please set us know if you have any questions.
Sincerely,
Lesley F.
Supervisor, Health Operations

June 22, 2015Dear [redacted],This is in response to your letter dated June 2, 2015.We reviewed our processing of claim [redacted] as well as the maternity care benefits in the 2014 Foreign Service Benefit Plan (FSBP) Brochure. Under the maternity care benefit on page 33 of our 2014 FSBP Brochure, we...

cover “Postnatal care." Postnatal care consists of medically necessary visits to a doctor following childbirth. We provide coverage for inpatient hospitals stays for childbirth (up to 48 hours for a vaginal delivery and 96 hours for a C-section.) We will cover an extended hospital stay if medically necessary.The service rendered was a week long stay, following childbirth, at a separate facility where new mothers can rest before taking on the full responsibility of caring for a newborn. These are not medically necessary services and are not covered by the Plan.All benefits are subject to the definitions, limitations and exclusions in the FSBP Brochure and are payable only when we determine they are medically necessary. The Brochure also states, in the Introduction on page three: “This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure."On 11/25/2014 we received an appeal from [redacted] disputing the handling of claim [redacted]. A letter response was mailed to him on 12/22/2014 upholding the original handing of the claim and advising him that if he did not agree, he had the right to request a review from the Office of Personnel Management (OPM). A copy of this letter is enclosed.Please let us know if you have any questions.Sincerely,Ms. Leslie F.