State agency ยท Massachusetts Health Policy Commission, Office of Patient Protection
Massachusetts Office of Patient Protection: external review
Massachusetts runs independent review of health plan decisions based on medical necessity. You have 4 months from your plan's final denial letter to ask, and an eligible request gets a final and binding decision.
Know before you go
You need your plan's final denial letter first (an internal appeal that was turned down). The page says an independent doctor or health care professional reviews decisions based on medical necessity. The state file for Massachusetts says the office does not accept requests by email and covers fully insured plans licensed in Massachusetts, not self-funded employer plans or Medicare. Check the date on your denial letter, which controls your deadline.
- Cost
- The state's external review overview gives a fee of $25 per review, no more than $75 a year, waived for financial hardship and refunded if the review is fully in your favor.
- Where
- Massachusetts
- How to start
- Fill in the external review form (English and Spanish versions are on the page) and send it with the final denial letter and any medical records by the secure online form, mail, fax or in person. For a fast review, fax the form and then call the office.
- Phone
- 800-436-7757, as printed on the provider's page
- Have ready
- Your plan's final denial letter; The external review form; Medical records that support the request; Your doctor's certification if you need a fast review
Where this comes from
- Provider
- Massachusetts Health Policy Commission, Office of Patient Protection
- Source we read
- https://www.mass.gov/request-an-external-review-of-a-health-insurance-decision
- Date we read it
- . This is not a fresh check.
- Date the provider printed
- Not displayed
- What we checked
- We read the provider's public page. We have not verified availability, eligibility or outcomes for any individual.
Other starting points
- Program or service
Beneficiary and Family Centered Care Quality Improvement Organizations: find yours
The Medicare contractors that handle fast appeals when hospital or other care is ending too soon, and complaints about the quality of care. Each state is assigned to one of two organizations.
From Centers for Medicare & Medicaid Services
- Program or service
California Department of Managed Health Care: Independent Medical Review
California's regulator for managed care plans reviews denials of medical services, emergency payment and experimental treatment through Independent Medical Review. One form starts either a review or a consumer complaint.
From California Department of Managed Health Care
- Program or service
Center for Medicare Advocacy self-help materials
Downloadable self-help toolkits for Medicare denials involving home health care, outpatient therapy and skilled nursing facility care, from a nonprofit law organization. The page describes materials, not a helpline.
From Center for Medicare Advocacy