I have health insurance through my employer. Am I eligible for external review?

You are eligible if your plan is fully insured. You are not eligible for external review through the Office of Patient Protection if you are a member of 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, you should ask your employer or plan administrator for more information about the external review process offered under your plan.

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-funded plan. Contact your employer to find out if your plan is self-insured.

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

No. You should contact one of the following for assistance with a self-insured plan:

  • Federal Office of Employee Benefits Security Administration (Federal Department of Labor rules) 1-866-444-3272
  • Federal websites for information about health insurance: www.healthcare.gov or http://cciio.cms.gov/
  • Health Care for All (the federally-designated Massachusetts health insurance consumer assistance program) 1-800 272-4232 or www.massconsumerassistance.org

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

You are not eligible for this external review process for Medicare or Medicaid (MassHealth) denials. However, both plans do provide appeal rights, so please see the numbers at the end of this document to find out whom to call for more information about your rights.

What if I have further questions about external review?

Call the Office of Patient Protection at 1-800-436-7757. The office is open from 8:45 a.m. to 5:00 p.m. Monday through Friday. You can also leave a message at any time.

Where can I get a copy of the law and regulations regarding managed care consumer protections?

The law and current regulations can be found on this OPP website. There are also other helpful links you may want to visit, such as the Division of Insurance at www.mass.gov/doi.