External Review Eligibility

I have health insurance through my employer. Am I eligible for external review through the Office of Patient Protection?

You may be able to request external review through the Office of Patient Protection if your health insurance is a fully insured Massachusetts health plan. If your health plan is based in a different state, you may contact the agency that regulates health insurance in that state.  Members of self-insured health plans are not eligible for external review through the Office of Patient Protection, but may have other appeal rights.

What does "self-insured" mean?

Under a self-insured or self-funded plan, your 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-insured plan. Contact your employer to find out if your plan is self-insured.  If you are a member of a self-insured plan, ask your employer or plan administrator for more information about the external review process offered under your plan.

Can the Office of Patient Protection help me with an appeal if I am in a self-insured plan?

Only fully-insured Massachusetts plans may be eligible for the Office of Patient Protection external review process.  You may have other options for external review. Contact  the following for assistance with a self-insured plan:

I am covered by Medicare or Medicaid (MassHealth), but have no additional coverage. Am I entitled to external review?

For information about appealing Medicare coverage denials, you may contact:

    Center for Medicaid and Medicare Services (CMS), 1-800-MEDICARE

    Medicare Advocacy Project, 617-371-1234

For information about appealing MassHealth/Medicaid denials, you may contact:

    MassHealth Customer Service, 1-800-841-2900

    Health Law Advocates, 617-338-5241

    Legal Aid

The Office of Patient Protection cannot accept external review requests for Medicare or MassHealth denials of coverage.

What if I have further questions about external review?

Call the Office of Patient Protection at 1-800-436-7757, or contact us by email at HPC-OPP@state.ma.us.

Where can I get a copy of the laws and regulations regarding health insurance consumer protections?

Information is available on-line, including the following websites:

    Office of Patient Protection

    Division of Insurance

    Massachusetts Trial Court Law Libraries

    U.S. Department of Labor, EBSA


Updated May 2014