Adverse determination means a determination by a carrier to deny or modify the services requested based on medical necessity.

 

C hapter 176O refers to the health insurance consumer protection law signed into law in July, 2000.

 

Eligible means that a request for external review meets the requirements defined in 105 CMR 128.404 and 128.405. A request for review must:

  1. Be on a form prescribed by the HPC;
  2. Include the signature of the insured or the insured's authorized representative consenting to the release of medical information;
  3. Include a copy of the written final adverse determination issued by the carrier;
  4. Include the $25 filing fee (waived in cases of financial hardship);
  5. Not involve a service or benefit that has been explicitly excluded from coverage by the carrier in its evidence of coverage; and
  6. 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 Massachusetts law 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 made after an insured has exhausted all remedies available through a carrier's formal internal grievance process.

 

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 105 CMR 128.311, a grievance not properly acted on by the carrier within the time limits required by 105 CMR 128.300 through 128.310 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 105 CMR 128.404 and 128.405. (See definition of eligible.)

  1. Self-insured, Medicare, and Medicaid plans are ineligible for external review under Chapter 176O.
  2. Requests for coverage of services or benefits that are specifically excluded from coverage by the carrier are not eligible for external review.
  3. The 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.

 

Medically necessary means health care services that are consistent with generally accepted principles of professional medical practice as determined by whether:

  1. the service is the most appropriate available supply or level of service for the insured;
  2. is known to be effective based on scientific evidence, professional standards, and expert opinion, in improving health outcomes;
  3. or for services and interventions not in widespread use, is based upon scientific evidence.

 

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 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-insured means that an employer pays for its employees' health care claims directly from its own funds rather than purchasing health insurance. Self-insured employee health benefit plans are exempt from state law and instead are subject to federal (ERISA) law.

 

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.