If your provider organization recently denied your internal appeal, you may request an external review of that decision.
The Office of Patient Protection (OPP) administers an external review process where decisions by a Risk-Bearing Provider Organization (RBPO) or Accountable Care Organization (ACO) can be reviewed by an independent doctor or health care professional.
You have 30 days from receipt of a written resolution letter from your RBPO/ACO responding to your internal appeal to request an external review. If your request for an external review is eligible for this process, you will receive a final and binding decision from the external reviewer.
Not every request is eligible for external review. The Office of Patient Protection will determine if your request is eligible.
What is an External Review?
As a patient of a Risk-Bearing Provider Organization (RBPO) or an Accountable Care Organization (ACO), your health care providers work together to coordinate your health care. If you disagree with a decision by your health care provider you may request an internal appeal. By requesting an internal appeal, you are asking the RBPO/ACO to reconsider that decision.
If you disagree with the outcome of the internal appeal, you may request an external review. External review is a process where you may seek an independent review of a decision by an RBPO/ACO on referrals, the type or intensity of care, timely access to care, and other concerns. The RBPO/ACO external review process is limited to RBPO/ACO decisions and does not consider denials of health insurance coverage. An independent doctor or other health care professional reviews your medical records and other information submitted and issues a final decision. An external review may only be requested after your internal appeal is complete.
Eligibility
Not all requests for external review are eligible. The Office of Patient Protection will determine if your request is eligible based on these rules:
- You must receive your care from a health care provider within an Accountable Care Organization (ACO) or a Risk-Bearing Provider Organization (RBPO). If you are unsure, you may ask your health care provider.
- You must have a commercial health insurance plan for which the ACO or RBPO assumes some financial risk.
- MassHealth (Medicaid) and Medicare members are not eligible for this process.
- You received a written resolution notice from the ACO or RBPO denying your internal appeal within the last 30 days. If the ACO or RBPO failed to respond to your appeal, please contact OPP.
My health insurance company sent me a denial notice. Am I eligible for external review through OPP?
The process described on this page is for patients who have received a written resolution letter from an ACO or RBPO. For denials of coverage or final adverse determination notices received from health insurance companies, there is a separate process. See here for more information about how to request an external review of a health insurance decision.
What You Need
- Completed RBPO/ACO External Review Request Form PDF (English) (more versions listed below)
- Written Resolution Letter from the Risk-bearing Provider Organization or Accountable Care Organization indicating that your internal appeal is complete
- Relevant medical records or other documentation to support your request
- You do not need to pay a fee to request an RBPO/ACO external review
Forms
Please note: These are different versions of the same form. You are only required to fill out one of these forms.
Secure Online RBPO/ACO External Review Form (online submission only)
RBPO/ACO External Review Form.pdf (mail or fax submission)
RBPO/ACO External Review Form.docx (mail or fax submission)
RBPO/ACO External Review Request Form (Spanish).pdf (mail or fax submission)
RBPO/ACO External Review Request Form (Spanish).docx (mail or fax submission)
How to Submit Your Completed Request
You must submit your external review request form to OPP within 30 days of receiving your written resolution letter. Requests may be submitted online, by mail, or by fax. We do not recommend sending your request or any personal health information by email because communications via email are not secure.
Online
Complete all necessary pages of the OPP external review request form through our secure online form. You will be asked to upload the written resolution letter from your RBPO/ACO and any relevant medical records you wish to include.
By mail
Please note: At this time OPP may accept mail only through United States Postal Service with no signature of receipt required. Correspondence mailed that requires a signature or uses other delivery services will be returned to sender.
Please mail your completed request form and supporting documentation to:
Health Policy Commission
Office of Patient Protection
50 Milk Street, 8th Floor
Boston, MA 02109
By fax
You may fax your completed request form and supporting documentation to 617-624-5046.
After You Submit Your Request
You will either receive a letter from OPP stating that your request is eligible for external review or you will receive a letter from OPP stating that your request is ineligible and the reason why it is ineligible.
If your request is eligible, the letter will notify you which external review agency is handling your request. If you want to provide additional documentation or medical records for your appeal, you must send those records to the external review agency directly within 5 days of OPP’s letter. If you have additional information to submit on an expedited external review request, please call OPP.
FAQs about the RBCO/ACO Appeals Process
About Risk-bearing Provider Organizations and Accountable Care Organizations
What is a Risk-bearing Provider Organization (RBPO) or an Accountable Care Organization (ACO)?
A RBPO/ACO is a group of health care providers that works together to coordinate your health care and enters into financial agreements with health insurance companies to do so. ACOs/RBPOs are typically accountable to the health insurance company for spending against a budget and may earn financial incentives for meeting agreed-upon quality performance targets. For more information about ACOs, see the Health Policy Commission's ACO Policy Brief #1.
How do I know if my health care providers participate in a RBPO/ACO?
You should ask your health care provider if he or she is part of a provider organization that has been certified by the Division of Insurance as an RBPO or certified by the Health Policy Commission as an ACO.
Additional Resources
The HPC Accountable Care Organization (ACO) Certification Program
Information on Risk-bearing Provider Organizations certified by the Division of Insurance
Guidance for ACOs/RBPOs
These resources are intended to provide additional guidance to risk-bearing provider organizations (RBPO) and accountable care organizations (ACO) establishing an appeals process pursuant to 958 CMR 11.00.
Final RBPO/ACO Appeals Regulation (958 CMR 11.00) (9/7/2018)
Secure Online RBPO/ACO External Review Request Form
RBPO/ACO External Review Request Form PDF
RBPO/ACO External Review Request Form PDF (Spanish)
Updated RBPO/ACO Appeals Sample Notice
Internal Appeal Process
What is an internal appeal?
You may have a disagreement with your health care provider about the care that you are receiving. For example, your health care provider may refer you to a certain specialist, but you prefer to see another specialist. Or, your health care provider may recommend one course of treatment, but you think another course of treatment is best given your prior medical history. If you disagree with a decision by your health care provider you may request an internal appeal. By requesting an internal appeal, you are asking the RBPO/ACO to reconsider that decision.
As a MassHealth member, may I submit an internal appeal to the RBPO/ACO?
No. MassHealth, MassHealth ACO, Medicare, or Medicare Advantage patients are not eligible for this process because there are other appeal rights available through MassHealth and Medicare. Contact MassHealth Customer Service at (800) 841-2900 for more information about appealing a MassHealth decision. Contact Medicare at (800) 633-4227 for information about Medicare coverage and appeals.
Who should I contact to request an internal appeal?
You should contact your RBPO/ACO directly to request an internal appeal. A notice stating how to file an appeal should be posted at your primary care provider’s office, and you may request information about appeals and it must be provided to you.
How much time will it take to decide my internal appeal?
The RBPO/ACO must resolve your appeal in writing within 14 calendar days of receiving your request. If you have an urgent medical need, you may request an expedited external review which must be resolved within 3 business days of receiving your request for an internal review.
What if the RBPO/ACO fails to respond to my internal appeal within 14 calendar days or 3 business days for expedited appeals?
If the RBPO/ACO does not provide a written resolution within 14 calendar days of your internal appeal or 3 business days of your expedited appeal, then you may request an external review through the Office of Patient Protection.
Does my appeal need to be in writing?
No. Your RBPO/ACO may not require you to submit an appeal in writing. If you submit an oral appeal via telephone or in-person, the RBPO/ACO must write down the substance of your appeal and send you a copy of that written description of your oral appeal.
Will my RBPO/ACO continue providing treatment or services during the appeal?
An RBPO/ACO may not terminate any medical or behavioral health services being provided to you during the internal appeal or external review, including medical or behavioral health services which began prior to your appeal and are the subject of the appeals process.
How will the RBPO/ACO respond to my appeal?
The RBPO/ACO must provide you with a written resolution letter detailing its decision on your appeal.
What happens if the RBPO/ACO denies my internal appeal?
If your RBPO/ACO denies your requested referral, treatment, or service by issuing a written resolution letter following the internal appeal and you still have a concern, you may request an external review of that decision through the Office of Patient Protection.
External Review Process
When can I request an external review?
You have 30 days from receipt of a written resolution from your RBPO/ACO to request an external review.
How can I request an external review?
Complete the OPP external review request form, submit that form with your written resolution 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. See here for more information about eligibility.
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?
If you are eligible for an external review, OPP will assign the request to an independent external review agency. External review agencies will make a decision on your case within 21 calendar days. This 21-day period begins the day the external review agency receives your case from OPP.
What if I have an urgent medical need and cannot wait 21 days for a decision?
You may request an expedited review if you believe you have an urgent medical need. In this case, the external review agency must first decide whether there is an urgent medical need. If so, the final decision by the external review agency will be issued within 72 hours of receiving the case from OPP.
Is there a fee to request an external review?
No. You do not need to pay a fee to request an external review.
Who conducts the external review?
Independent, experienced doctors or other health care professionals will perform the review. The professionals assigned to the review work in the same area of health care under review. Four external review agencies currently facilitate the reviews under a contract with the Commonwealth:
- The Island Peer Review Organization (IPRO)
- Independent Medical Expert Consulting Services (IMEDECS)
- Maximus Federal Services, Inc. (Maximus)
- ProPeer Resources (ProPeer)
The Office of Patient Protection does not conduct the reviews.
Does my RBPO/ACO 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?
You can download the form from the Forms section of this page.
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 5 calendar days of OPP’s letter. If your external review is expedited, you must send additional records to the external review agency within 24 hours of your request for expedited external review. Due to the short timeframe, if you have additional information to submit on an expedited external review request, please call OPP.
What is the standard that the external review agency uses to determine whether my request should be granted?
The external review agency will decide whether the requested referral, treatment, or service is likely to produce a more clinically beneficial outcome than what the RBPO/ACO is recommending.
What factors does the external review agency consider in determining whether the requested referral, treatment, or service is likely to produce a more clinically beneficial outcome than what the RBPO/ACO is recommending?
To make that determination, the external review agency must consider:
(a) The Patient’s clinical history, including prior clinical relationships; (b) The availability, within the RBPO or ACO, of a health care professional with the appropriate training and experience to meet the particular health care needs of the Patient, including timely access; (c) Generally accepted principles of professional medical practice; (d) The efficacy of the requested treatment or service, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; and (e) Other factors the external review agency considers relevant to the Patient’s ability to access the requested referral, treatment, or service.
Contact OPP
Phone
Main
(800) 436-7757
Translation services available.
TTY and ASCII Users
Voice and Hearing Users
(800) 720-3479
People who are deaf, hard of hearing, late deafened,
or speech disabled may reach OPP with MassRelay.