External Review Eligibility

Not all requests for external review are eligible. OPP will determine if your request is eligible based on these rules:

• If you receive health insurance from your employer, your health insurance product must be fully-insured (you can ask your employer if you’re not sure).
• Your health insurance product is licensed in Massachusetts.
• Your health insurance company must cover the denied service or treatment when it is medically necessary. The service that you are requesting cannot be explicitly excluded from coverage. For example, a health insurance company may state in its member handbook that it does not cover orthotics even if medically necessary.
• You received a notice from your health insurance company denying your internal appeal within the last 4 months or you submitted an expedited internal appeal and your request for an expedited external review at the same time.
• You may be eligible for external review if you received a surprise medical bill and your health insurance company has not complied with federal law. Please see our FAQ for more information.

Eligibility by Health Insurance Product Type

Product type	Submit a request for external review to OPP?
Fully-insured product, licensed in Massachusetts	Yes.
Self-insured product	No. Ask your health insurance company or your employer for its external review process, or contact the resources listed below.
Fully-insured product, licensed out-of-state	No. Click here to contact the agency that regulates health insurance in that state.

To find out what type of health insurance product you have you may contact your employer’s human resources department or your health insurance company’s member services.

Who can assist me with an external review if my health insurance is a self-insured product?

If you are a member of a self-insured product, your employer or health insurance company can help you navigate the external review process. You may also contact the following for assistance:

• U.S. Department of Labor, Employee Benefits Security Administration, 1-866-444-3272
• Federal websites for information about health insurance: https://www.healthcare.gov/ or http://cciio.cms.gov
• Health Law Advocates, 617-338-5241

I have health insurance through my employer. Am I eligible for external review through the Office of Patient Protection?

It depends. Some jobs offer health insurance products that are "fully-insured," while some products offered are "self-insured." OPP handles external reviews only for fully-insured health insurance products licensed in Massachusetts. If you are unsure what type of product you have, contact your employer’s human resources department to find out.

I am covered by Medicare or Medicaid (MassHealth). Am I entitled to external review through OPP?

No. OPP’s process is only for patients with commercial insurance.

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

For information about appealing MassHealth denials, you may contact:

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