When filing a claim for covered services, bills and receipts should be itemized and show:

• Patient name, date of birth, address, phone number, and relationship to enrollee.
• Patient’s Plan identification number.
• Name, address, and tax identification number of the person or company providing the services or supplies.  We do not need the tax ID number for providers outside the U.S.
• Date(s) of service, or date(s) supplies were furnished.
• Diagnosis or a description of your symptoms (not required for prescription medicine receipts).
• Charge for each service or supply.
• A brief description of each service or supply.
• If you have another health plan as your primary payor, you must send a copy of the explanation of benefits (EOB) you received from that payor (for example, the Medicare Summary Notice).
• Bills for private duty nursing care must show that the nurse is a Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.). You also should include the initial history and physical, treatment plan indicating expected duration and frequency from your attending physician or other health care professional, and notes from the nurse.
• Claims for rental or purchase of durable medical equipment must include the purchase price, a prescription, and a statement of medical necessity including the diagnosis and estimated length of time needed.
• Claims for dental services submitted to FSBP must include a copy of the dentist’s itemized bill (including the required information listed above) and the dentist’s Federal Tax ID Number. We do not have separate dental claim forms.

Click here for more information on how to submit claims.

The process to submit a claim online is simple: login to the Member Portal with your username and password. Once inside the portal, under the Secure Forms tab, select “Submit A Claim.” Follow the screen prompts to upload your PDF claim documents. You have the option to include questions or comments, or to send your claim to a specific Health Benefits Officer. Please ensure your name and member ID number appear on the claim. If you are serving overseas, note that using State Department mail (Pouch Mail) will delay your claim’s processing significantly.

Follow the Federal Employees Health Benefits Program disputed claims process outlined in Section 8 of the FSBP Plan Brochure if you disagree with our decision on your claim. 

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For additional information on NAIC rules regarding the coordinating of benefits, visit the NAIC website at www.NAIC.org.

Visit the FSBP provider search page. Enter your search terms and click “Search.” Choose the appropriate network option: either the “Foreign Service Benefit Plan – Aetna Choice POS II”; or the “NetCare-Guam.”

The provider should call 202-833-5751.

• For Self Only (401) enrollment, the deductible is $300 for in-network providers (including Guam) and providers outside the U.S., and $400 for out-of-network providers (including Guam).
• For Self Plus One (403) enrollment, the deductible is $600 for in-network providers (including Guam) and providers outside the U.S., and $800 for out-of-network providers (including Guam).
• Under a Self and Family (402) enrollment, the deductible is $600 for in-network providers (including Guam) and providers outside the U.S., and $800 for out-of-network providers (including Guam).

Login to Aetna’s secure member website Select “ID card” at the top of the page, and then choose to print/download additional ID cards or view your ID card. To order a replacement ID card, you can call 202-833-4910.

You can update your address in the Member Portal.  Login, or register if you are a first-time user. Go to Member Profile and select the “click to update” button.  Then enter the desired information and click save.

Aetna’s secure member website is a system that provides members with access to information and tools regarding their health. Every enrollee and dependents ages 14 and older have their own separate login credentials for this portal. In your Aetna secure member website account, you can track and sign up for wellness incentives, take your Health Risk Assessment and see your results, enroll in electronic funds transfer (EFT), view your Explanations of Benefits (EOBs) and the status of your claims. The AFSPA Member Portal is a system for all AFSPA members. It can be used to upload and submit claims, update contact information, and enroll in and manage AFSPA Ancillary Insurance Programs. The Member Portal is only available to the AFSPA member/subscriber, not dependents. We recommend having a Member Portal account in order to allow for the fastest processing of claims.

When you leave Federal service, you may become eligible for Temporary Continuation of Coverage (TCC), the Federal government’s version of COBRA, for up to 18 months. If you lose coverage because you no longer qualify as a family member of a Federal employee, you may become eligible for TCC for up to 36 months. Dependent children may be covered under your Self and Family or Self Plus One enrollment until age 26. At age 26, your child may be eligible for TCC for up to 36 months. For more information about TCC, please visit OPM’s TCC site. Annuitants who are eligible under the Foreign Service Retirement System may enroll in this Plan for the first time as an annuitant. All other retirees must have been enrolled in the Plan while an active employee to elect the Plan during retirement. To learn more about continuing your FEHB benefits into retirement, please visit OPM’s website on health insurance for Retirees and Survivors.

Virtual Second Opinion – Cleveland Clinic

FSBP has a special arrangement with the Clinic by Cleveland Clinic and Children’s Hospital to provide our members with the option of a second opinion for certain diagnoses received from a foreign provider. The Overseas Second Opinion benefit provides access to nationally recognized specialists for a second opinion via the Clinic by Cleveland Clinic and Children’s Hospital. Once you obtain the second opinion, you choose whether to proceed with the original course of treatment, seek out another opinion, or arrange care with an alternate physician. To determine if you are eligible to participate, e-mail the Plan at secondopinion@aetna.com.

Children’s National RSO Program

The Plan has a special arrangement with Children’s National Hospital to provide patients who receive treatment in foreign countries access to Virtual Second Opinions. This program allows you to have your medical diagnosis and treatment reviewed by expert specialists from Children’s National Hospital who can help you with many health challenges.

The Children’s National RSO Program provides patients access to leading pediatric specialists, without ever having to travel outside of their home. For each RSO, our physician reviews the patient’s medical information and compiles their findings into a comprehensive written report.

• Physician to Physician
• Easy Online submission of demographics & studies
• Direct access to a designated clinical & financial teams

Process for Requesting an RSO

• We assign an expert
• Review medical information
• Delivery of complete second opinion packet
• Financial review
• Post opinion follow up

To request a Virtual Second Opinion for treatment received outside the U.S., simply complete the online intake form Children’s National – Online Request Form.

 

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If you would like to see a second provider of your choice while serving overseas, the consultation and any medically necessary tests or services will be covered in the same way as any overseas provider. For more information about coverage while overseas, visit our Overseas page.

FSBP provides access to Aetna’s Aexcel specialists network. Aexcel is a designation for doctors and doctor groups in 12 medical specialty areas:

• Cardiology
• Obstetrics and gynecology
• Cardiothoracic surgery
• Orthopedics
• Gastroenterology
• Otolaryngology/ENT
• General surgery
• Plastic surgery
• Neurology
• Urology
• Neurosurgery
• Vascular surgery

Doctors with the Aexcel designation will have a blue star next to their listing in the provider search results. The Evaluation Standards are:

• Volume: In order to compare like practices, Aetna first evaluates volume by identifying doctors who have managed at least 20 episodes of care for Aetna members over the past three years.
• Clinical Performance: Doctors must meet standards in one of five categories.  Those categories are (1) use of technology; (2) alignment with Institutes of Quality®; (3) certification by an external entity such as the National Committee for Quality Assurance; (4) performance-based improvement model; or (5) claim-based measures.
• Efficiency: Aetna examines what these doctors charge Aetna members for services and how many and what types of services they perform.  Aetna considers all costs of care, the number of patients served with chronic or complex conditions, and risk-adjustment factors like age, gender, and disease risk.

For those benefits where copayments, coinsurance or deductibles apply, we pay 100% of the Plan allowance for the rest of the calendar year after your expenses total to:

• For Self Only enrollment $5,000 and for Self Plus One or Self and Family enrollment $7,000 for in-network providers (including Guam) and providers outside the 50 United States and when you use the Plan’s network retail pharmacy through Express Scripts (ESI), or home delivery (mail order) through the Express Scripts PharmacySM, or purchase prescriptions outside the 50 United States from a retail pharmacy or Military Treatment Facility (including Guam);
• For Self Only enrollment $7,000 and for Self Plus One or Self and Family enrollment $9,000 for in- and out-of-network providers combined (including Guam) and when you use the Plan’s network retail pharmacy through Express Scripts or home delivery (mail order) through the Express Scripts PharmacySM or purchase prescriptions outside the 50 United States from a retail pharmacy or Military Treatment Facility (including Guam).

For Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member’s claims will no longer be subject to associated cost-sharing amounts for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum. Any expenses incurred that apply toward the catastrophic out-of-pocket maximum for in-network or out-of-network apply toward both in and out-of-network limits. This catastrophic protection out-of-pocket maximum is combined for medical/surgical, mental health/substance misuse disorder, and pharmacy. There are some expenses that do not fall under this provision; see your FSBP Brochure , Section 4, Your Costs for Covered Services.

This does not mean the doctor does not provide quality services. It could be that Aetna does not have enough information available to evaluate a particular doctor or the doctor’s specialty is not one of the 12 specialty categories. An Aexcel designation is not a guarantee of service quality or treatment outcome. Therefore, the Aexcel designation should not be the only reason for choosing a specialty doctor. The Aexcel designation is only a guide, and all ratings have a chance for error.