Adverse determination means a decision by a health insurance company to deny or modify the services requested based on medical necessity.
Chapter 176O refers to Massachusetts General Laws chapter 176O , the Massachusetts health insurance consumer protection law.
Eligible means that a request for external review meets the requirements defined in 958 CMR 3.404 and 958 CMR 3.405. A request for review must:
- Be on a form prescribed by the Health Policy Commission;
- Include the signature of the insured or the insured's parent or guardian consenting to the release of medical information;
- Include a copy of the written final adverse determination issued by the carrier;
- Include the $25 filing fee, a request that the filing fee be waived for financial hardship, or no fee if the patient has already filed three external review requests that year.
- Not involve a service or benefit that has been explicitly excluded from coverage by the health plan in its evidence of coverage; and
- Result from a carrier's issuance of a final notice of adverse determination.
In addition, the coverage in question must be fully insured and issued in Massachusetts. Self-insured plans, Medicare and Medicaid are not covered by Chapter 176O and are therefore not eligible for external review through OPP.
Expedited request means a request for a quick resolution to a grievance involving immediate and urgently needed services. A request may be expedited during the internal appeal process and/or during the external appeal process.
Final adverse determination means an adverse determination or denial made after an insured has exhausted all remedies available through a health plan’s formal internal grievance process.
Fully insured means a health plan purchased by an employer from an insurance company. Fully-insured plans are usually regulated by state government.
Health plan did not meet time frame means that the case was resolved in favor of the insured because the carrier did not issue a decision within the time periods required under the law. According to 958 CMR 3.311, a grievance not properly acted on by the carrier within the time limits required by 958 CMR 3.300 through 958.310 shall be deemed resolved in favor of the insured. During the screening process, if OPP sees evidence that the time frames were not met and there is no waiver of those time limits signed by the insured or the insured's authorized representative, OPP requests that the case be deemed resolved in favor of the insured.
Ineligible means that a request does not meet the requirements specified in 958 CMR 3.404 through 958 CMR 3.406. (See definition of eligible.)
- Self-insured, Medicare, and Medicaid plans are ineligible for external review under Chapter 176O.
- Requests for coverage of services or benefits that are specifically excluded from coverage by the carrier are not eligible for external review.
- For a standard external review insured must exhaust the carrier's internal appeal process and be issued a final adverse determination by the carrier in order to be eligible for external review, unless the carrier has waived the internal appeal.
For detailed rules, please see the Office of Patient Protection regulations at 958 CMR 3.000-3.700.
Medical Necessity or Medically Necessary means 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.
Nongroup insurance means health insurance that you buy for yourself or your family from the Health Connector or from an insurance company or insurance agent.
Open enrollment means that under Massachusetts and federal law there are only certain times during the year when individuals and families may buy nongroup health insurance coverage. The time when individuals and families can apply – the time when health insurers open plans to new members – is called “open enrollment.” This is similar to the process employers use to allow their employees to sign up or change plans during specified times only
Overturned means that the external review organization determined that the services being requested are both covered and medically necessary and that the health plan's decision should be reversed. The decisions of the external review organizations are final and binding.
Partially overturned means that the external review agency found that some of the services being requested are both covered and medically necessary and that the health plan's decision should be reversed in part. For example, an insured may have requested coverage of 12 additional physical therapy sessions. Upon review, the external review agency may have determined that it was medically necessary for three additional sessions to be covered.
Resolved means that a case was resolved in favor of the member without an external review. In certain circumstances, a health plan may receive additional information about a case and decide to reverse its denial before a decision has been made by the external review organization or before the case was sent to external review.
Self-funded/self-insured health plan means the employer pays the costs for its employees' health care directly instead of paying premiums to buy health insurance. Some self-insured employers hire insurance companies to process the paperwork, so it is not always easy to tell if you are in a self-funded plan. Contact your employer to find out if your plan is self-insured. Self-insured plans are usually regulated by the federal government.
Upheld means that the external review organization agreed with the decision of the health plan to deny coverage for the services that were the subject of the grievance. The decisions of the external review agencies are binding.
This is not an exhaustive list. Health care terminology and acronyms aren't always easy to understand. For further clarification and definitions, please consult the health insurance glossary from the U.S. Centers for Medicare & Medicaid Services.