Request an External Review of a Health Insurance Decision

What is an internal appeal?

When you receive health care, your doctor or health care provider requests payment or prior authorization from your health insurance company. Your health insurance company may refuse to pay for or authorize the service or treatment. If so, your health insurance company will send you a denial notice or explanation of benefits form explaining why the health insurance company refuses to pay or authorize. You may ask your health insurance company to reconsider that decision by requesting an internal appeal.

When can I request an internal appeal?

You have 180 days from the date of the denial notice or explanation of benefits form to request an internal appeal.

Who should I contact to request an internal appeal?

You should contact your health insurance company directly to request an internal appeal. The denial notice or explanation of benefits form should have information about internal appeals. If not, you should read your member handbook or call your health insurance company to learn how to submit an internal appeal.

How much time will it take to decide my internal appeal?

Your health insurance company must resolve your appeal in writing within 30 calendar days of receiving your request for an internal appeal.

If your appeal requires the review of medical records, the 30 calendar day timeframe begins as soon as you submit a signed release form to the health insurance company.

Can my health insurance company delay the internal appeal process?

No. Unless you agreed in writing to extend the time frame, your health insurance company must make a decision within 30 calendar days.

What if my health insurance company fails to respond to my internal appeal within 30 calendar days?

If the health insurance company does not provide a written resolution within 30 calendar days, then the health insurance company must pay for the treatment or service that was originally denied. No external review is necessary.

Is the health insurance company ever required to act in less than 30 days?

The health insurance company must decide the internal appeal faster when you are appealing coverage of immediate and urgently needed services and you request an expedited internal appeal. In this case, your health insurance company must resolve your appeal in writing within 72 hours of receiving it. If you think this applies to you, request an expedited internal appeal from your health insurance company.  

Does my appeal need to be in writing?

No. Your health insurance company must accept your appeal by phone, by mail, in person, by fax, or by e-mail.

Also, if you submit your appeal orally, the health insurance company must send you a written summary of your complaint within 15 days of receipt.

Will my health insurance company pay for treatments and services during the appeal process?

If your appeal deals with ongoing services or treatment, those services or treatments must be covered by the health insurance company until the end of the internal appeal. In addition, your health insurance company must continue to pay for your other medical care in the normal course of business.

How will the health insurance company respond to my appeal?

Within 30 calendar days, the health insurance company must provide you with a written response. Your health insurance company will send you a final adverse determination letter if the health insurance company decided that the treatment or service is not medically necessary, and therefore will not pay for or authorize it.

What happens if I receive a final adverse determination letter in response to my appeal?

If your health insurance company still refuses to pay for or authorize the treatment or service by issuing a final adverse determination letter following the internal appeal, you may be able to request an external review of that decision through the Office of Patient Protection. You have 4 months from receipt of a final adverse determination letter from your health insurance company to request an external review.

Where can I get assistance in requesting an internal appeal?

Health Law Advocates (617-338-5241) provides free legal assistance to people who meet income guidelines and other acceptance criteria.

Is my request eligible for external review?

Not all requests for external review are eligible. OPP will determine if your request is eligible based on these rules:

• If you receive health insurance from your employer, your health insurance product must be fully-insured (you can ask your employer if you’re not sure).
• Your health insurance product is licensed in Massachusetts.
• Your health insurance company must cover the denied service or treatment when it is medically necessary. The service that you are requesting cannot be explicitly excluded from coverage. For example, a health insurance company may state in its member handbook that it does not cover orthotics even if medically necessary.
• You received a notice from your health insurance company denying your internal appeal within the last 4 months or you submitted an expedited internal appeal and your request for an expedited external review at the same time.
• You may be eligible for external review if you received a surprise medical bill and your health insurance company has not complied with federal law. Please see our FAQ for more information.

How does my health insurance product type impact eligibility?

To find out what type of health insurance product you have you may contact your employer’s human resources department or your health insurance company’s member services.

When can I request an external review?

You have 4 months from receipt of a final adverse determination letter from your health insurance company to request an external review.

Your health insurance company may refuse to pay for or authorize a certain service or treatment. If so, your health insurance company will send you a denial notice or explanation of benefits form explaining why the health insurance company refuses to pay or authorize.

Before requesting an external review, you must ask your health insurance company directly to reconsider this decision though an internal appeal. Your health insurance company should explain how to submit an internal appeal. See above FAQ for more information on internal appeals.

If your health insurance company still refuses to pay for or authorize the treatment or service by issuing a final adverse determination letter following the internal appeal, you may be able to request an external review of that decision through the Office of Patient Protection.

How can I request an external review?

Complete the OPP external review request form, submit that form and your final adverse determination letter and any relevant medical records to the Office of Patient Protection (OPP) via mail, fax, or in-person. OPP will review for eligibility and contact you with any questions.

Please do not send personal health information or other confidential information to OPP by email because OPP cannot guarantee the confidentiality and security of that information.

How long does an external review take?

External review agencies will make a decision on your case within 45 days. This 45-day period begins the day the external review agency receives your case from OPP.

You may request an expedited review in certain circumstances. In this case, the external review agency must make its decision within 72 hours. OPP can help you find out if your case qualifies for this faster review.

Does an external review cost anything?

Yes. You usually must pay a $25 fee to request an external review. If you request multiple external reviews in a year, you will not pay more than $75 in fees. If the external review is resolved completely in your favor, the Commonwealth of Massachusetts will refund your $25 payment.

OPP may waive this fee in situations of financial hardship. If this applies to you, you can note this on the request form.  

Who conducts the external review?

Independent, experienced doctors or other health care professionals will perform the review. These professionals work in the same area of health care under review. Three external review agencies currently perform the reviews under a contract with the Commonwealth:

• Independent Medical Expert Consulting Services (IMEDECS)
• The Island Peer Review Organization (IPRO)
• MAXIMUS Federal Services, Inc.
• ProPeer Resources

The Office of Patient Protection does not conduct the reviews.

Does my health insurance company have to follow the external review agency's decision?

Yes. External review decisions are final and binding.

How can I get a copy of OPP’s external review request form?

The forms are available here.

Can I take part in the external review?

The external review is a review of medical records not a face-to-face or telephonic meeting. OPP recommends that you submit all materials, medical records, correspondence, and other related documentation with your external review request form.

If you have information that you want the reviewer to consider, it is important that you gather that information before submitting your external review request.

What if I have more information to share after my initial request?

If your request is eligible, OPP will send you a letter notifying you which external review agency is handling your request. If you want to provide additional documentation or medical records for your review, you must send those records to the external review agency directly within 10 days of OPP’s letter. If you have additional information to submit on an expedited external review request, please call OPP.

Does my health insurance company have to pay for treatment during the external review?

You have two business days from receipt of a final adverse determination to submit a request for continuation of coverage with your request for an expedited external review.

The external review agency will order the continuation of coverage where it determines that substantial harm to your health may result if coverage is not continued.

If the external review agency orders continuation of coverage, your health insurance company must pay for the denied treatment during the course of the external review. The external review agency’s decision about continuation of coverage does not impact the final decision, which could still be denied.

What is a surprise medical bill?

You may receive a surprise medical bill if you unknowingly received services from a doctor or health care provider that does not participate in your health insurance company’s network (an “out-of-network provider”). When you receive a service from an out-of-network provider, the out-of-network provider may bill you directly for the total charges or the difference between what your health insurance company covered and the total charges. These bills are called surprise medical bills.

What are my protections against surprise medical bills?

In certain circumstances, a new federal law prevents health care providers and facilities from billing patients for more than their in-network cost sharing (including co-payments, co-insurance, and deductibles). Please visit this website for more information about the federal protections against surprise billing.

Can my surprise medical bill be resolved through the external review process?

Patients who received a surprise medical bill and have completed the internal appeal process with their health insurance company may request an external review to determine whether their health insurance company properly complied with federal surprise billing and cost-sharing protections. You may submit a request for an external review directly to MAXIMUS Federal Services, the federal contractor performing reviews. You may also submit the external review request to OPP, which will forward it to MAXIMUS Federal Services.

What is a "final adverse determination?"

A final adverse determination is the letter you receive from your health insurance company in response to your internal appeal. This letter notifies you that your health insurance company has reached a final decision that the treatment or service is not medically necessary, and therefore the health insurance company will not pay for or authorize it. This is the letter that you need to submit along with your external review request form.

How is medical necessity defined?

The Massachusetts legal definition of “medical necessity” is as follows:

Health care services that are consistent with generally accepted principles of professional medical practice as determined by whether the service: (a) is the most appropriate available supply or level of service for the insured in question considering potential benefits and harms to the individual; (b) is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; or (c) for services and interventions not in widespread use, is based on scientific evidence.

What is meant by "explicitly excluded?"

Your health insurance company is required to give you an “evidence of coverage,” which is a document that tells you what is covered by your specific plan. It will also have a section of exclusions. For example, some plans specifically exclude acupuncture; others might exclude coverage for dental procedures. Because these exclusions apply to all such services for all members, a request for a non-covered service is not eligible for external review. Only denials based on medical necessity are eligible for external review.