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Frequently Asked Questions about the OPP External Review Process

Do you have questions about requesting an external review? See below for a list of our most frequently asked questions.

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When can I request an external review?

You have 4 months from receipt of a final adverse determination letter from your health insurance company to request an external review.

Your health insurance company may refuse to pay for or authorize a certain service or treatment. If so, your health insurance company will send you a denial notice or explanation of benefits form explaining why the health insurance company refuses to pay or authorize.

Before requesting an external review, you must ask your health insurance company directly to reconsider this decision though an internal appeal. Your health insurance company should explain how to submit an internal appeal. See here for more information on internal appeals.

If your health insurance company still refuses to pay for or authorize the treatment or service by issuing a final adverse determination letter following the internal appeal, you may be able to request an external review of that decision through the Office of Patient Protection.

How can I request an external review?

Complete the OPP external review request form, submit that form and your final adverse determination letter and any relevant medical records to the Office of Patient Protection (OPP) via mail, fax, or in-person. OPP will review for eligibility and contact you with any questions. See here for more information about eligibility.

Please do not send personal health information or other confidential information to OPP by email because OPP cannot guarantee the confidentiality and security of that information.

 

Additional Resources   for How can I request an external review?

Open DOCX file, 93.71 KB,  Health Insurance External Review Form DOCX (English) (English, DOCX 93.71 KB)
Open PDF file, 363.46 KB,  External Review Form (Spanish) (English, PDF 363.46 KB)
Open DOCX file, 77.22 KB,  External Review Form (Spanish) (English, DOCX 77.22 KB)
Open PDF file, 420.77 KB,  Health Insurance External Review Form PDF (English) (English, PDF 420.77 KB)

How long does an external review take?

External review agencies will make a decision on your case within 45 days. This 45-day period begins the day the external review agency receives your case from OPP.

You may request an expedited review in certain circumstances. In this case, the external review agency must make its decision within 72 hours. OPP can help you find out if your case qualifies for this faster review.

Does an external review cost anything?

Yes. You usually must pay a $25 fee to request an external review. If you request multiple external reviews in a year, you will not pay more than $75 in fees. If the external review is resolved completely in your favor, the Commonwealth of Massachusetts will refund your $25 payment.

OPP may waive this fee in situations of financial hardship. If this applies to you, you can note this on the request form.  

Who conducts the external review?

Independent, experienced doctors or other health care professionals will perform the review. These professionals work in the same area of health care under review. Three external review agencies currently perform the reviews under a contract with the Commonwealth:

  • Independent Medical Expert Consulting Services (IMEDECS)
  • The Island Peer Review Organization (IPRO)
  • MAXIMUS Federal Services, Inc.
  • ProPeer Resources

The Office of Patient Protection does not conduct the reviews.

Does my health insurance company have to follow the external review agency's decision?

Yes. External review decisions are final and binding.

How can I get a copy of OPP’s external review request form?

You can download the form below:

Health Insurance External Review Form PDF (English)
Health Insurance External Review Form DOCX (English)
Health Insurance External Review Form PDF (Spanish)
Health Insurance External Review Form DOCX (Spanish)

Can I take part in the external review?

The external review is a review of medical records not a face-to-face or telephonic meeting. OPP recommends that you submit all materials, medical records, correspondence, and other related documentation with your external review request form.

If you have information that you want the reviewer to consider, it is important that you gather that information before submitting your external review request.

What if I have more information to share after my initial request?

If your request is eligible, OPP will send you a letter notifying you which external review agency is handling your request. If you want to provide additional documentation or medical records for your review, you must send those records to the external review agency directly within 10 days of OPP’s letter. If you have additional information to submit on an expedited external review request, please call OPP.

Does my health insurance company have to pay for treatment during the external review?

You have two business days from receipt of a final adverse determination to submit a request for continuation of coverage with your request for an expedited external review.

The external review agency will order the continuation of coverage where it determines that substantial harm to your health may result if coverage is not continued.

If the external review agency orders continuation of coverage, your health insurance company must pay for the denied treatment during the course of the external review. The external review agency’s decision about continuation of coverage does not impact the final decision, which could still be denied.

Surprise Medical Bills

What is a surprise medical bill?

You may receive a surprise medical bill if you unknowingly received services from a doctor or health care provider that does not participate in your health insurance company’s network (an “out-of-network provider”). When you receive a service from an out-of-network provider, the out-of-network provider may bill you directly for the total charges or the difference between what your health insurance company covered and the total charges. These bills are called surprise medical bills.

What are my protections against surprise medical bills?

In certain circumstances, a new federal law prevents health care providers and facilities from billing patients for more than their in-network cost sharing (including co-payments, co-insurance, and deductibles). For more information about the federal protections against surprise billing, please visit this website: https://www.cms.gov/nosurprises/consumers.  

Can my surprise medical bill be resolved through the external review process?

Patients who received a surprise medical bill and have completed the internal appeal process with their health insurance company may request an external review to determine whether their health insurance company properly complied with federal surprise billing and cost-sharing protections. You may submit a request for an external review directly to MAXIMUS Federal Services, the federal contractor performing reviews. You may also submit the external review request to OPP, which will forward it to MAXIMUS Federal Services.

Useful Definitions for External Review

What is a "final adverse determination”?

A final adverse determination is the letter you receive from your health insurance company in response to your internal appeal. This letter notifies you that your health insurance company has reached a final decision that the treatment or service is not medically necessary, and therefore the health insurance company will not pay for or authorize it. This is the letter that you need to submit along with your external review request form.

How is medical necessity defined?

The Massachusetts legal definition of “medical necessity” is as follows:

Health care services that are consistent with generally accepted principles of professional medical practice as determined by whether the service: (a) is the most appropriate available supply or level of service for the insured in question considering potential benefits and harms to the individual; (b) is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; or (c) for services and interventions not in widespread use, is based on scientific evidence.

What is meant by "explicitly excluded?"

Your health insurance company is required to give you an “evidence of coverage,” which is a document that tells you what is covered by your specific plan. It will also have a section of exclusions. For example, some plans specifically exclude acupuncture; others might exclude coverage for dental procedures. Because these exclusions apply to all such services for all members, a request for a non-covered service is not eligible for external review. Only denials based on medical necessity are eligible for external review.

Related Links

For additional resources please refer to the Additional Resources section below: 

Additional Resources   for Related Links

Open file,  External Review Eligibility
Open file,  External Review Process Overview
Open file,  Frequently Asked Questions about the OPP External Review Process
Open file,  How to Request an External Review
Open file,  Frequently Asked Questions about Internal Appeals
Open file,  Office of Patient Protection
Open file,  Health care terminology and acronyms aren't always easy to understand. For further clarification and definitions, please consult the health insurance glossary from the U.S. Centers for Medicare & Medicaid Services.

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