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State guide

Massachusetts

Pick the kind of plan you have to see who to call first. Massachusetts can only help with plans it regulates.

On this page 8

Which plan do you have? Who to call first, by coverage

The short version for Massachusetts

In Massachusetts, medical necessity denials go to the Office of Patient Protection, not the Division of Insurance, and an outside reviewer's decision is final and binding. There is a $25 fee that can be waived for hardship and is refunded if you win completely; the state says that generally over 40% of external reviews are resolved in the patient's favor. Free help is available from the Health Care For All HelpLine and the Attorney General's health care helpline.

At a glance: independent review for plans Massachusetts regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
Massachusetts Division of Insurance (DOI), Consumer Service Unit · 617-521-7794 or toll free (877) 563-4467
Independent review
A state process (External review through the Office of Patient Protection)
Deadline to request it
4 months after you receive the final adverse determination letter (the denial of your internal appeal)
Cost
$25 per external review, no more than $75 a year; waived for financial hardship; refunded by the Commonwealth if the review is resolved completely in your favor
Decision time
45 days from the day the external review agency receives your case; fast track: 72 hours

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

The state process covers only fully insured plans licensed in Massachusetts. The Office of Patient Protection and the Division of Insurance both say to ask your employer's human resources department or benefits coordinator (or your insurer's member services) whether your plan is fully insured or self-insured (self-funded). Self-insured plans use the plan's own external review; plans licensed in another state go to that state's regulator.

Independent (external) review

Process
A state process. Run by Office of Patient Protection (Massachusetts Health Policy Commission), which assigns a contracted external review agency.
Where you file
regulator
How
Complete the Office of Patient Protection external review request form and send it with your final adverse determination letter and any medical records through the secure online form, by mail, in person, or by fax (617-624-5046). The office cannot accept requests by email. For an expedited review, fax the form and then call 800-436-7757.
Which denials qualify
Denials based on medical necessity, appropriateness of health care setting and level of care, or effectiveness of treatment, for a service the plan covers when medically necessary (not a service that is explicitly excluded). You may also be eligible if you received a surprise medical bill and the insurer has not followed federal law.
Appeal to the plan first?
Yes, you need the insurer's final adverse determination. Exception: if your health care professional certifies that delay would pose a serious and immediate threat to your health, you can request an expedited external review at the same time as an expedited internal appeal.
Published results
The Office of Patient Protection states that generally over 40% of external review decisions are resolved in favor of the patient (no year given). Source

Official page Request form

General rules and what to send: how external review works, how to request it.

Free help in Massachusetts

Medicare and Medicaid in Massachusetts

Medicare counseling
SHINE (Serving the Health Insurance Needs of Everyone) Program · 1-800-243-4636 . Free help with Medicare appeals.
Medicaid agency
Executive Office of Health and Human Services, Office of Medicaid (MassHealth); hearings are held by the Board of Hearings
Fair hearing deadline
The Board of Hearings must receive your request within 60 calendar days from the date you received the MassHealth notice (120 calendar days if you never received a written notice). Your notice states the deadline that applies to you.
Good to know
To keep your benefits during the appeal, the hearing request must be received before the benefits stop or within 10 calendar days of receiving the notice, whichever is later; you may have to repay the cost if you lose. You can file by mail, fax (617-887-8797), encrypted email, in person, or by calling MassHealth Customer Service at (800) 841-2900.

Medicaid appeals page How Medicaid appeals work

State laws that can help

  • Step therapy. Insurers must grant a step therapy exception on listed grounds (the required drug is contraindicated, expected to be ineffective, already tried and failed, or you are stable on your current drug), must answer within 3 business days (24 hours if delay risks your health), and a missed deadline means the exception is granted.

    Massachusetts General Laws chapter 176O, section 12A (Chapter 254 of the Acts of 2022)

  • Mental health parity. The Commissioner of Insurance must evaluate and resolve consumer complaints that an insurer is violating mental health and substance use parity laws, and can fine insurers $100 per day per affected member.

    Massachusetts General Laws chapter 26, section 8K

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. Request an External Review of a Health Insurance Decision (Mass.gov)
  2. How to request an external review with the Office of Patient Protection
  3. External Review Process Overview (Mass.gov)
  4. Frequently Asked Questions about the OPP External Review Process
  5. External Review Eligibility (Mass.gov)
  6. Filing An Insurance Complaint (Division of Insurance)
  7. How To Contact The Division Of Insurance
  8. Health Care Resources at the Attorney General's Office
  9. How to appeal a MassHealth decision
  10. SHINE Program (Mass.gov)
  11. Massachusetts SHINE listing (SHIP National Technical Assistance Center)
  12. CMS: State External Appeals Review Processes
Not confirmed (6)
  • Free consumer help programs. state pages disagree: the Attorney General's health care resources page prints the Health Care Helpline as (888) 830-6277, while the Attorney General's contact directory lists the Health Care Division helpline as (617) 963-2100 and gives (888) 830-6277 to the Insurance and Financial Services Division
  • Free consumer help programs. the federal directory lists Massachusetts as having a Consumer Assistance Program, but the HelpLine page does not state that designation or mention appeals specifically
  • How to file for independent review. one state page says requests can be filed through a secure online form while the frequently asked questions page lists only mail, fax or in person; the address of the online form was not captured
  • The Medicare counseling program's phone number. taken from the federal SHIP directory (shiphelp.org)
  • Notes on Medicaid appeals. the rule that members of a MassHealth managed care plan must finish the plan's internal appeal before the Board of Hearings was not confirmed on a page that loaded, so it is not stated
  • Published results of independent review. general statement without a year; the annual report figures were not loaded

Sources last checked . Found a mistake? Report it.