FEHB appeals

If you’re having a problem, we’re here to help.

If you have any problems with Sharp Health Plan or one of our providers, please let us help. You can reach our Customer Care team for support at 1-800-359-2002.

Initial denial of pre-service requests

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review as described below. If your claim is in reference to a contraceptive, call Customer Care at 1-800-359-2002. To ask us in writing to reconsider our initial request, you must:

1. Write to us within six months from the date of our decision; and
2. Send your request to us at: Sharp Health Plan, Attention: Appeal/Grievance Department, 8520 Tech Way, Suite 200, San Diego, CA 92123-1450; and
3. Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in your Federal Employees Health Benefits (FEHB) Brochure; and
4. Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the Office of Personnel Management (OPM) review stage described in Step 4 of the disputed claims process detailed in Section 8 of your FEHB Brochure.

We have 30 days from the date we receive your written request for consideration to complete one of the following:

1. Pre-certify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
   You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
3. Write to you and maintain our denial.

For urgent services

If you have a serious or life-threatening condition (one that may cause permanent loss of bodily function or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 1-800-359-2002. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM at 1-202-606-0737 between 8 a.m. and 5 p.m. Eastern Time.