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Guide Frequently Asked Questions about the RBPO/ACO Appeals Process

Do you have questions about requesting an internal appeal or external review of an RBPO/ACO decision? See below for a list of our most frequently asked questions.

Table of Contents

What is a Risk-bearing Provider Organization (RBPO) or an Accountable Care Organization (ACO)?

A RBPO/ACO is a group of health care providers that works together to coordinate your health care and enters into financial agreements with health insurance companies to do so. ACOs/RBPOs are typically accountable to the health insurance company for spending against a budget and may earn financial incentives for meeting agreed-upon quality performance targets. For more information about ACOs, see the Health Policy Commission's ACO Policy Brief #1

 

How do I know if my health care providers participate in a RBPO/ACO?

You should ask your health care provider if he or she is part of a provider organization that has been certified by the Division of Insurance as an RBPO or certified by the Health Policy Commission as an ACO.  

Additional Resources for How do I know if my health care providers participate in a RBPO/ACO?

What is an internal appeal?

You may have a disagreement with your health care provider about the care that you are receiving. For example, your health care provider may refer you to a certain specialist, but you prefer to see another specialist. Or, your health care provider may recommend one course of treatment, but you think another course of treatment is best given your prior medical history. If you disagree with a decision by your health care provider you may request an internal appeal. By requesting an internal appeal, you are asking the RBPO/ACO to reconsider that decision.  

As a MassHealth member, may I submit an internal appeal to the RBPO/ACO?

No. MassHealth, MassHealth ACO, Medicare, or Medicare Advantage patients are not eligible for this process because there are other appeal rights available through MassHealth and Medicare. Contact MassHealth Customer Service at (800) 841-2900 for more information about appealing a MassHealth decision.  Contact Medicare at (800) 633-4227 for information about Medicare coverage and appeals.

Who should I contact to request an internal appeal?

You should contact your RBPO/ACO directly to request an internal appeal. A notice stating how to file an appeal should be posted at your primary care provider’s office, and you may request information about appeals and it must be provided to you.

How much time will it take to decide my internal appeal?

The RBPO/ACO must resolve your appeal in writing within 14 calendar days of receiving your request. If you have an urgent medical need, you may request an expedited external review which must be resolved within 3 business days of receiving your request for an internal review.

What if the RBPO/ACO fails to respond to my internal appeal within 14 calendar days or 3 business days for expedited appeals?

If the RBPO/ACO does not provide a written resolution within 14 calendar days of your internal appeal or 3 business days of your expedited appeal, then you may request an external review through the Office of Patient Protection.

Does my appeal need to be in writing?

No. Your RBPO/ACO may not require you to submit an appeal in writing. If you submit an oral appeal via telephone or in-person, the RBPO/ACO must write down the substance of your appeal and send you a copy of that written description of your oral appeal.

Will my RBPO/ACO continue providing treatment or services during the appeal?

An RBPO/ACO may not terminate any medical or behavioral health services being provided to you during the internal appeal or external review, including medical or behavioral health services which began prior to your appeal and are the subject of the appeals process.

How will the RBPO/ACO respond to my appeal?

The RBPO/ACO must provide you with a written resolution letter detailing its decision on your appeal.

What happens if the RBPO/ACO denies my internal appeal?

If your RBPO/ACO denies your requested referral, treatment, or service by issuing a written resolution letter following the internal appeal and you still have a concern, you may request an external review of that decision through the Office of Patient Protection.

When can I request an external review?

You have 30 days from receipt of a written resolution from your RBPO/ACO to request an external review.

How can I request an external review?

Complete the OPP external review request form, submit that form with your written resolution letter and any relevant medical records to the Office of Patient Protection (OPP) via mail, fax, or in-person. See here for more information about submitting a request for external review. 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.

How long does an external review take?

If you are eligible for an external review, OPP will assign the request to an independent external review agency. External review agencies will make a decision on your case within 21 calendar days. This 21-day period begins the day the external review agency receives your case from OPP.

What if I have an urgent medical need and cannot wait 21 days for a decision?

You may request an expedited review if you believe you have an urgent medical need. In this case, the external review agency must first decide whether there is an urgent medical need. If so, the final decision by the external review agency will be issued within 72 hours of receiving the case from OPP.

Is there a fee to request an external review?

No.  You do not need to pay a fee to request an external review.

Who conducts the external review?

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

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

 

The Office of Patient Protection does not conduct the reviews.

Does my RBPO/ACO 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 from the Office of Patient Protection website.

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 5 calendar days of OPP’s letter. If your external review is expedited, you must send additional records to the external review agency within 24 hours of your request for expedited external review. Due to the short timeframe, if you have additional information to submit on an expedited external review request, please call OPP.

What is the standard that the external review agency uses to determine whether my request should be granted?

The external review agency will decide whether the requested referral, treatment, or service is likely to produce a more clinically beneficial outcome than what the RBPO/ACO is recommending.

What factors does the external review agency consider in determining whether the requested referral, treatment, or service is likely to produce a more clinically beneficial outcome than what the RBPO/ACO is recommending?

To make that determination, the external review agency must consider:

(a) The Patient’s clinical history, including prior clinical relationships; (b) The availability, within the RBPO or ACO, of a health care professional with the appropriate training and experience to meet the particular health care needs of the Patient, including timely access; (c) Generally accepted principles of professional medical practice; (d) The efficacy of the requested treatment or service, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; and (e) Other factors the external review agency considers relevant to the Patient’s ability to access the requested referral, treatment, or service.

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