Do I need to submit a claim form?

When you use a network provider, you do not need to file a claim. Just show your ID card, and your provider files the claim for you. It is important to carry your ID card with you at all times, especially when you travel in the United States, since it includes the address your provider will need to submit your claims. Also, you might need to purchase prescriptions at a Network pharmacy and you need your ID card to do so.

How do I obtain a claim form?

For your convenience, you may print a copy of the form by going to the Forms Librarysection of this website.

Where do I send my claim?

PPO providers ordinarily file claims for you. However, if you need to submit a claim please use the following address:

Medical claims:
Foreign Service Benefit Plan EDI# 62413
1716 N Street NW
Washington, DC 20036

How do I file a claim?

When you use a network provider, you do not need to file a claim. Present your ID card at the time of service and your provider will file the claim for you. When you use non-network providers you may have to file your own claim. To file your claim, download the form in the Forms Library. Follow the instructions for completing the form and mail to the address provided on the form. If you have questions, you may contact us at 202-833-4910 to speak with a representative.

How do I file a claim electronically?

Claims must be submitted using the FOREIGN SERVICE BENEFIT PLAN (FSBP) secure website. Please go to:

http://afspa.org/products-services/fsbp/fsbp411/submit-claims/

Please follow the instructions to submit your claims. If you have any questions, please contact the FSBP at health@afspa.org or 202-833-4910.
 

What should I do to file a disputed claim?

Follow the Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies, including a request for preauthorization/prior approval.

How do I precertify for a hospital admission?

You, your representative, your doctor, or your hospital must call the Plan at least two working days before admission. The toll-free number is 1-800-593-2354. Provide the following information:

• Enrollee's name and Plan identification number.
• Patient's name, birth date and phone number.
• Reason for proposed hospitalization.
• Name and phone number of the doctor who will admit you.
• Number of planned days in the hospital.

We will then tell the doctor and hospital the number of approved days of confinement for the care of the patient's condition. Written confirmation of the Plan's certification decision will be sent to you, your doctor, and the hospital.

Do I still need to precertify for hospital admission if I use a PPO hospital?

Yes. The Federal government requires that all members of a fee-for-service plan must precertify their hospital admissions.  We will reduce our benefits for the inpatient hospital stay or residential treatment care by $500 if no one contacts us for precertification.  If the stay is not medically necessary, we will not pay any benefits.

Exceptions:  You do not need precertification in these cases:
• You are admitted to a hospital or residential treatment center outside the 50 United States.  However, the Plan will review all services to establish medical necessity.  We may request medical records in order to determine medical necessity.
• You have another group health insurance policy that is the primary payer for the hospital stay.
Medicare Part A is the primary payer for the hospital stay.  Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days or you have no Medicare lifetime reserve days left, then we will become the primary payer and you must precertify.

What other services require preauthorization?

Other services require precertification or prior authorization.  You, your representative, your doctor, or treating facility must call us at 1-800-593-2354 (except for prior authorization on prescription drugs – see below) before the admission or care, such as:

• Home health care

• Hospice care;

• Organ/tissue transplants;

• Skilled nursing facility admission; and

• Mental health and substance abuse treatment.

• Prescription drugs. Some medications are not covered unless you receive approval through a coverage review (prior authorization). This review uses Plan rules based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe, and effective. To request a coverage review, contact Express Scripts, the Plan’s Pharmacy Benefit Manager at 1-800-818-6717 (TDD: 1-800-759-1089 for the hearing impaired).

If no one contacted us for specified services such as Home health care, Hospice care, Skilled nursing facility care, or Mental health and substance abuse care, we will pay a reduced benefit as referenced in the appropriate benefit section of our Brochure.

Note:  We do not require precertification, preauthorization, or concurrent review if you receive treatment outside the 50 United States.  However, the Plan will review all services to establish medical necessity.   We may request medical records in order to determine medical necessity.  

Note:  We do not require precertification, preauthorization, or concurrent review when Medicare Part A and/or Part B or another group health insurance policy is the primary payer.  Precertification, preauthorization and concurrent review are required, however, when Medicare or the other group health insurance policy stops paying benefits for any reason.

Note:  We do not require prior authorization for the purchase of certain prescription drugs when Medicare Part B or Part D is the primary payer or you are outside the 50 United States and purchase them from a retail pharmacy outside the 50 United States.

What do I do in case of an emergency?

When there is an emergency admission you, your representative, the doctor, or the hospital must telephone 1-800-593-2354 within two business days following the day of admission, even if the patient has been discharged from the hospital.

How do I find a network provider?

You may visit our Locate a Providerpage to look up providers who participate in the network. You may also call 202-833-4910, and we will assist you in locating a participating provider near your home or office.

While every effort is made to include accurate, complete and current provider information, keep in mind that provider information may have changed since it was last updated. Please call your doctor before your appointment to confirm his/her network status.

Can I obtain a paper directory listing network providers?

While we understand your desire for a paper directory, they become outdated quickly. New providers are added frequently to our growing network.

Print a copy of the directory from the Provider Searchtool by selecting the "Print" option at the top of your search results.

Can I access network providers while traveling?

Members have access to providers in our PPO network virtually anywhere throughout the United States. Whether you are traveling on vacation, business travel or college, you and your eligible dependents can find providers who participate in our PPO network.K

When my doctor refers me to a specialist, is it my responsibility to confirm that the specialist also participates in the PPO network?

Yes. While we encourage network physicians to refer their patients to other network physicians, this may not always be possible. We recommend that members always confirm that the physician is a member of our PPO network. Likewise, if your physician refers you to a hospital, please confirm that the hospital participates in our PPO network.

Can I self-refer?  That is, can I choose a specialist on my own?

Yes, you can self-refer and choose specialists without being referred by your physician.

How do I get my physician to participate in the PPO network?

If your physician does not currently participate in our network, you may submit a physician nomination form to have him/her considered. Fill out the patient section and ask your physician to complete the rest. After we receive the form, we will follow through with the process, which can take up to six months to complete. If you have questions, please call 202-833-4910 for assistance.

Download a Provider Nomination form now >>

How can I replace a lost ID card?

To obtain a replacement ID card, you may order a new card online through My Online Services, or call 202-833-4910.