My plan offers several levels of internal grievance. How much time can it take to decide my case?
Unless you agree to extend the time frame, Massachusetts law requires your health plan to provide you with a written resolution of your grievance within 30 business days, regardless of the number of levels of review. (Plans subject to regulation by the federal Department of Labor may be required to act more quickly in certain circumstances. Please call 1-866-444-3272 or visit their website at www.dol.gov/ebsa for further information about federal requirements.)
Can my health plan delay the internal grievance process?
Not without your permission. Unless you have agreed in writing to an extension of the time frame, your health plan must make a determination on your internal grievance within 30 business days of receipt of the grievance. If medical records are requested, the 30-day period begins on the date you submit a signed release form to the plan.
What if my health plan fails to reach a timely decision on my internal grievance?
If the health plan does not issue a written resolution within 30 business days, and you have not agreed to an extension of time, the adverse determination is considered reversed and the health care services must be provided. No external review is necessary.
Are there any circumstances under which the health plan has to act more quickly?
The law requires the health plan to issue a decision regarding inpatient care prior to the patient's discharge from the hospital. Health plans are required to act within 48 hours when a physician certifies that there is substantial risk of immediate harm to a patient, or within five days for terminally ill patients. If you think you may be entitled to an expedited review, call the Office of Patient Protection at 1 800-436-7757 to discuss your case.
As noted above, federal requirements may also require a plan to act more quickly in some circumstances; however, the Office of Patient Protection enforces only state law.
I called my health plan with a complaint, but I was told to put it in writing. Do I have to start over and mail in my appeal?
No. The law requires health plans to accept grievances by phone, by mail, in person or electronically (by fax or e-mail). In addition, if you submit your grievance orally, the health plan is required to send you a written summary of your complaint within 48 hours. If you think your health plan is not complying with the law, call the Office of Patient Protection at 1-800-436-7757.
Can my health plan cut off my benefits while it is considering my appeal?
The law requires that the health plan continue to cover treatment during the internal appeals process if the treatment was initially authorized by the health plan and was not terminated because of a specific time or episode-related exclusion in the contract. If you think you may be eligible for continuing coverage during the internal appeal, call the Office of Patient Protection at 1-800-436-7757 to discuss your case. If eligible, the coverage must continue at the health plan's expense until the health plan issues its final decision.
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-funded plan. Contact your employer to find out if your plan is self-insured. Self-insured plans are usually regulated by the federal government.