The plan refuses to pay for treatment that you and your child's PCP believe your child needs
The plan tells you that it will stop paying for treatment
Check the benefits handbook or contact a Member Services Representative at the plan for more information about how to appeal a decision. Ask for a copy of your plan's policy on prior approval and appeals. The Member Services Representative will work with you to help you find the best way to address the problem.
Tip: Federal law requires that a health plan allow you to appeal a decision up to 180 days from the service date. It is best to file an appeal as soon as you can. Remember to keep a written record of everything you do and everyone you speak to. Also, keep copies of any letters you send or forms you fill out.
If your appeal is denied by your health plan, you may have additional rights through the Office of Patient Protection (OPP) at the Massachusetts Department of Public Health. Information about additional rights should be provided in the final denial letter you receive from your health plan. Please note that in some plans, decisions are not eligible for outside review by the OPP.
This information is provided by the Division for Children & Youth with Special Health Needs within the Department of Public Health.
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