External Review Process Overview
What is an external review?
External review provides an independent review process for individuals covered by a fully-insured Massachusetts health plan who have been denied benefits for reasons of medical necessity. In order to be eligible for external review, the medical or behavioral health service or supply being requested must be a covered benefit in the particular health plan contract -- that is, it cannot be explicitly excluded from the health plan. Medical professionals who are not affiliated with your health plan review your case and issue a determination. The results of external reviews are binding on your health plan.
What is a fully-insured health plan?
Fully-insured: A health plan purchased by an employer from an insurance company. Fully-insured plans are usually regulated by state government.
Self-funded/self-insured: 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. Self-insured plans are usually regulated by the federal government.
Contact your employer to find out if your plan is fully-insured or self-insured.
How is medical necessity defined?
Medical necessity means health care services that are consistent with the generally accepted principles of professional medical practice as determined by whether the service:
- Is the most appropriate available supply or level of service for the insured in question considering potential benefits and harms to the individual;
- Is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; or
- For services and interventions not in widespread use, is based on scientific evidence.
When can I request an external review?
Usually, you must file an internal grievance with your health plan and wait for its final decision. If the health plan still refuses to cover the requested service, you have four (4) months from the date you receive a final adverse determination to file for external review. The application for external review must be sent to the Office of Patient Protection at the Health Policy Commission, to the address or fax number on the external review request form. If you are requesting an expedited review, it is not necessary to wait for the health plan to make its decision. You may file a request for an expedited external review at the same time that you file a request for an expedited review with the health plan.
Does an external review cost anything?
There is a $25 fee to file a request for external review, and the Office of Patient Protection will waive this fee in cases of financial hardship. The remainder of the cost of review is paid by the health insurance company.
How long does an external review take?
External review agencies will make a decision on your case within 45 days. The 45-day period begins on the day the external review agency receives the request for external review from the Health Policy Commission. In some instances, you may request an expedited or fast review. If your physician or health care provider certifies that an expedited review is necessary because a delay in providing the requested services would pose a serious and immediate threat to your health, the external review agency must make a decision within 72 hours.
Who conducts the external review?
The Office of Patient Protection does not hear appeals or perform the reviews. The Health Policy Commission has contracts with three external review agencies to perform the reviews: the Island Peer Review Organization (IPRO), located in New York, Independent Medical Expert Consulting Services (IMEDECS), located in Pennsylvania, and ProPeer Resources, located in Utah. The reviews are conducted by independent experienced physicians or other health care professionals from all over the United States who typically treat the health care conditions under review.
Does my health plan have to abide by the decision?
Yes. By law, external review decisions are binding.
How can I obtain a copy of an external review application?
Your health plan must explain the procedures for requesting an external review and include the external review forms whenever it issues a final adverse determination. You can also download the form from the Office of Patient Protection website .
Can I participate in the external review?
The external review is a paper review. The independent physician or other health care professional reviews the medical records of the case. There is no hearing or other proceeding. If you have information that you want the reviewer to consider, it is important that you provide this information with your request for external review.
What if I have additional information to share with the external review agency?
After you file a request for standard (non-expedited) external review and if your case is eligible for external review, the Office of Patient Protection will send you a letter to let you know which external review agency will handle your case. If you send additional information to the assigned external review agency so that the external review agency receives it within ten days after the date of this letter, then the external review agency will consider your additional information. You can send additional information later or for an expedited review, but the external review agency will not be required by law to consider the additional information.
Does my health plan have to continue to pay for my treatment during the external review?
Possibly, depending on your case and if you request “continuation of coverage.” The law permits an insured to ask the external review agency to order continuation of coverage or treatment where substantial harm to the patient's health may result if the coverage is not continued. This request must be made by the end of the second business day following the insured's receipt of the final adverse determination. Additionally, the treatment must have been initially authorized by the health plan and not terminated because of a specific time or episode-related exclusion in the contract. If the external reviewer orders continuation, the health plan must continue to pay for treatment during the external review.
Updated May 2014