When you or a family member receives medical services or treatment, your health care provider will submit a request for payment to your insurance company. Payment is usually sent to the provider and you will receive an Explanation of Benefits (EOB) that includes the treatment, date of service, what is covered and what the provider may bill you for (co-pays, co-insurance or deductible). If your insurance company believes that it is not required to pay for the treatment or service, the company will send a denial notice or letter. Your denial letter should explain the services that are being denied and why. You have the right to ask your insurance company to reconsider this decision through a member grievance/internal appeal.
When your insurance company denies your member grievance/internal appeal, you have the right to an external review. The Office of Patient Protection provides an independent appeal process if you:
- Are covered by a fully-insured Massachusetts health plan (ask your employer if you’re not sure),
- Received the appeal denial letter within the past 4 months, and
- Were denied benefits for reasons of “medical necessity” or because the treatment is “experimental/investigational,” but not if the services are explicitly excluded from your plan
Medical professionals who are not affiliated with your health plan but treat patients with similar conditions review your case and issue a determination. Your health plan must abide by the decision of the external review. Typically, 30-40% of external reviews result in favor of the patient. Expedited appeals are also available, in which case you do not always need to wait for the result of the internal appeal.