GEHA (Government Employees Health Association) Letter of Medical Necessity Guide
How to write an LMN and overturn a prior authorization denial with GEHA (Government Employees Health Association). Includes denial reasons, turnaround times, appeals address, and clinician tips.
Quick Facts
- Avg Turnaround: 30 days standard, 72h expedited (OPM FEHB contract)
- Appeals Address: GEHA Appeals, PO Box 4665, Independence, MO 64051
- Provider Portal: https://www.geha.com/providers
Why GEHA Denies Prior Authorizations
- 1. Not medically necessary per GEHA Brochure criteria
- 2. Step therapy not completed
- 3. Non-preferred specialty drug
- 4. Quantity limit
Clinician Tips for GEHA
- ✓ GEHA is a federal employee health benefit plan under OPM's FEHB program — governed by FEHBA federal law, NOT state insurance law
- ✓ Reference the GEHA benefit brochure section (e.g., Section 5, page XX) in LMNs — not state insurance codes
- ✓ Express Scripts is the PBM for the GEHA High and Standard plans; pharmacy PA via CoverMyMeds
- ✓ GEHA Connection Dental federal plan and GEHA medical plan are separate products
Not-for-profit association serving federal employees under FEHB. Governed by OPM, not state law. Express Scripts PBM. Second-largest FEHB plan after BCBS FEP.
GEHA Prior Authorization FAQ
Why does GEHA deny prior authorizations?
The most common GEHA denial reasons are: Not medically necessary per GEHA Brochure criteria; Step therapy not completed; Non-preferred specialty drug; Quantity limit.
How long does GEHA take to review a prior authorization?
GEHA typically responds in 30 days standard, 72h expedited (OPM FEHB contract).
What should a Letter of Medical Necessity for GEHA include?
An LMN for GEHA (Government Employees Health Association) should reference the specific medical policy or coverage bulletin, document failed first-line therapies with dates, include current labs and ICD-10 codes, and cite supporting clinical guidelines. Not-for-profit association serving federal employees under FEHB. Governed by OPM, not state law. Express Scripts PBM. Second-largest FEHB plan after BCBS FEP.