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External Review Process Overview

The Office of Patient Protection (OPP) administers an external review process where decisions by your health insurance company, based on medical necessity, can be reviewed by an independent doctor or health care professional.

You have 4 months from receipt of a final adverse determination letter from your health insurance company to request an external review. If your request for an external review is eligible for this process, you will receive a final and binding decision from the external reviewer.

Generally, over 40% of external review decisions are resolved in favor of the patient and, in those instances, the service or treatment must be covered by the health insurance company.

Not every request is eligible for external review. The Office of Patient Protection will determine if your request is eligible. 

 

What to know before requesting an external review:

When you receive health care, your doctor or health care provider requests payment or prior authorization from your health insurance company. Your health insurance company may refuse to pay for or authorize the 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.

You have the right to 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. 

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.

What is an external review?

External review is a process where you may seek an independent review of a health insurance company decision to refuse to pay for or authorize a treatment or service. External review is limited to health insurance company decisions based on medical necessity. An independent doctor or other health care professional reviews the medical records and other information submitted and issues a final decision.

How can I request an external review?

You must 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 on how to request an external review

 

Additional Resources for

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.

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.

More questions?

See our list of frequently asked questions about the external review process. 

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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