Massachusetts General Information and Internal Plan Review: Massachusetts’ external review process applies to any fully insured Massachusetts-based health plan. First file an internal grievance through your health plan, which the plan must resolve within 30 business days of receiving all necessary information unless you agree to extend the time frame. If the plan does not respond within 30 days, the services are automatically covered. An expedited appeal process is also available for immediate and urgently needed services. If you receive written notice of a final adverse determination from the health plan, you may file for external review.
The External Review Process: Whom to contact: | Office of Patient Protection, Massachusetts Department of Public Health | Who can appeal: | You, your provider (with consent), or your authorized representative | What you can appeal: | Any denial of a medically necessary service covered by the health plan. | When you can appeal: | You must file within 45 days of receipt of your health plan’s final adverse determination letter. | What to send: | Follow the procedures provided by your health plan or request an external review application from the Office of Patient Protection. | What you must pay: | $25 (may be waived for financial hardship) | What will happen: | The Department of Public Health will randomly assign your case to an external review agency. The review agency will evaluate the case and return a decision. | When you will get a decision: | Usually within 60 business days after the review agency receives the request from the Department of Public Health, although the review agency may request an additional 15 business days. | In urgent situations: | To be eligible for the expedited appeal process, your treating provider must submit a written certification to your insurer and send supporting documentation indicating that waiting through the standard appeal process is likely to cause a substantial risk of serious harm to the patient. After you have completed the internal expedited levels of review, the expedited external review will be completed within 5 business days. |
How to Get More Information: Office of Patient Protection, 800-436-7757 or fax 617-624-5046
www.state.ma.us/dph/opp/
Included within the Office of Patient Protection is the Office of the Managed Care Ombudsman, which is available to assist health plan members with questions and concerns regarding managed care, grievances, appeals, denials of care, continuity of care, and independent external reviews. Call 1-800-436-7757. Information updated as of 2-10-2005 |
