ACO or RBPO External Review Eligibility

Not all requests for external review are eligible. The Office of Patient Protection will determine if your request is eligible based on these rules:

• You must receive your care from a health care provider within an Accountable Care Organization (ACO) or a Risk-Bearing Provider Organization (RBPO). If you are unsure, you may ask your health care provider.
• You must have a commercial health insurance plan for which the ACO or RBPO assumes some financial risk.
• MassHealth (Medicaid) and Medicare members are not eligible for this process.  
• You received a written resolution notice from the ACO or RBPO denying your internal appeal within the last 30 days. If the ACO or RBPO failed to respond to your appeal, please contact OPP.

Who can assist me with an appeal if I am a MassHealth or Medicare member?

Who can assist me with an appeal if I am a MassHealth or Medicare member?

MassHealth and Medicare members cannot appeal through the Office of Patient Protection (OPP). OPP’s process is only for patients with commercial insurance.

For information about appealing MassHealth denials, you may contact:

• MassHealth Customer Service, 1-800-841-2900
• Health Law Advocates, 617-338-5241

For information about appealing Medicare coverage denials, you may contact:

• Center for Medicaid and Medicare Services (CMS), 1-800-MEDICARE
• Medicare Advocacy Project, 617-603-1700

My health insurance company sent me a denial notice. Am I eligible for external review through OPP?

The process described on this page is for patients who have received a written resolution letter from an ACO or RBPO. For denials of coverage or final adverse determination notices received from health insurance companies, there is a separate process. See here for more information about how to request an external review of a health insurance decision.