You have 30 days from receipt of a written resolution letter from your RBPO/ACO responding to your internal appeal 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.
Not every request is eligible for external review. OPP will determine if your request is eligible. See here to learn about eligibility.
What to know before requesting an external review:
As a patient of a Risk-Bearing Provider Organization (RBPO) or an Accountable Care Organization (ACO), your health care providers work together to coordinate your health care. 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.
Your RBPO/ACO should explain how to submit an internal appeal and have a notice available explaining your rights.
Your RBPO/ACO will respond to the internal appeal by issuing a written resolution letter. Upon receipt of that written resolution letter, you may be able to request an external review of that decision through OPP.
What is an RBPO/ACO external review?
External review is a process where you may seek an independent review of a decision by an RBPO/ACO on referrals, the type or intensity of care, timely access to care, and other concerns. The RBPO/ACO external review process is limited to RBPO/ACO decisions and does not consider denials of health insurance coverage. An independent doctor or other health care professional reviews your medical records and other information submitted and issues a final decision.
How can I request an RBPO/ACO external review?
You must complete the OPP external review request form, submit that form and your written resolution letter, and any relevant medical records or documents to 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
Who conducts the ACO or RBPO external review?
Independent, experienced doctors or other health care professionals, unrelated to your provider, will perform the review. These professionals work in the same area of health care under review. Four external review agencies currently perform the reviews under a contract with the Commonwealth:
- The Island Peer Review Organization (IPRO)
- Independent Medical Expert Consulting Services (IMEDECS)
- ProPeer Resources
- MAXIMUS Federal Sevices, Inc.
OPP does not conduct the reviews.
How long does an ACO or RBPO external review take?
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. 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 external review agency will issue its final decision within 72 hours of receiving the case from OPP. 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.
Contact for RBPO or ACO External Review Process Overview
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