MHBP Plan & Benefits FAQs
1. 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, since it includes the address your provider will need to submit your claims.
2. How do I obtain a claim form?
For your convenience, you may print a copy of the form by going to the forms section of this website.
3. Where do I send my claim?
Network providers ordinarily file claims for you. However, if you need to submit a claim please use the following address:
PO Box 8402
London, KY 40742-8402
For prescription drug claims:
Attn: Claims Department
P.O. Box 52196
Phoenix, AZ 85072-2196
For MHBP Dental Plan claims:
PO Box 8403
London, KY 40742
For MHBP Vision Plan claims:
P.O. Box 997105
Sacramento, CA 95899-7105
4. 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, access the claim here. 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 1-800-410-7778 to speak with a representative.
5. 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. Click here to access the appeals/disputed claims process.
6. What is precertification?
Before you're admitted to the hospital as an inpatient, you need to get your stay precertified. Precertification is the process by which we evaluate the medical necessity of your proposed stay and how many days are required to treat your condition. Any stay greater than 23 hours must be precertified, except maternity admission for a routine delivery.
OPM requires all Federal Employee Health Benefits Program (FEHBP) plans to precertify hospital stays. In most cases, your physician or hospital will take care of precertification. However, you are still responsible for ensuring that we are asked to precertify your care. So always verify with your physician or hospital that they have contacted us.
Warning: We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification.
We will not change the decision we make on medical necessity, unless we are misled by the information given to us. In addition, if the stay is not medically necessary, we will not pay any benefits for the room and board charges.
If you are admitted for services or supplies we don't cover - for example, non-covered cosmetic surgery - we will not pay any benefits.
7. 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 1-800-410-7778. 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.
8. 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 1-800-410-7778 within two business days following the day of admission, even if the patient has been discharged from the hospital.
9. What is preauthorization?
Preauthorization is required for:
- Inpatient hospital visits.
- Services for mental health and/or substance abuse.
- Certain prescription medications.
- Specific radiology and imaging services: CT/CAT scan, MRI, MRA, NC and PET scan. You must contact the plan before receiving these services at 1-800-410-7778.
- Injections for the treatment of back and neck pain
10. Do I still need to precertify for hospital admission if I use a Network hospital?
Yes. The Federal government requires that all members of a fee-for-service plan must precertify their hospital admissions.
11. How do I find a network provider?
You may visit our electronic directory to look up providers who participate in the network. If you prefer, you may send us an e-mail. You may also call the toll-free number on your ID card, 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.
12. 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 electronic directory by selecting the printer icon shown on the page after you have performed your search.
13. Can I access network providers while traveling?
Members have access to providers in our 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 national network.
14. When my doctor refers me to a specialist, is it my responsibility to confirm that the specialist also participates in the 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 network. Likewise, if your physician refers you to a hospital, please confirm that the hospital participates in our network.
15. How do I get my physician or dentist to participate in the network?
If your physician or dentist does not currently participate in our network, you may submit a physician nomination form or a dentist nomination form to have him/her considered. Fill out the patient section and ask your physician or dentist 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 send us an e-mail or call the toll-free number on your ID card for assistance.
16. How can I replace a lost ID card?
17. Whom do I notify if I change my address?
Please report your new address in writing to the address below:
P.O. Box 8402
London, KY 40742-8402
18. Whom do I notify to add/delete dependents?
Contact your Human Resources department and complete a Standard Form 2809.
To view and print PDF files, download and install the latest version of Adobe Reader.
Locate a Provider
Enter a Zip Code