More on appeals:
- For the state of Mass., you can find all kind of info below (URL not able to be posted):
What is an external review?
External review provides an independent review process for individuals covered by a fully insured Massachusetts health plan who have been denied benefits for reasons of medical necessity. In order to be eligible for external review, the service or supply being requested must be a covered benefit in the particular health plan contract -- that is, it cannot be explicitly excluded from the health plan. Medical professionals who are not affiliated with your health plan review your case and issue a determination. The results of external reviews are binding on your health plan.
How is medical necessity defined?
Medical necessity means health care services that are consistent with the generally accepted principles of professional medical practice as determined by whether the service:
1. Is the most appropriate available supply or level of service for the insured in question considering potential benefits and harms to the individual;
2. Is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; or
3. For services and interventions not in widespread use, is based on scientific evidence.
When can I request an external review?
First you must file an internal grievance with your health plan. If the health plan still refuses to cover the requested service, you have 45 days from the date you receive a final adverse determination to file for external review. The application for external review must be sent to the Office of Patient Protection in the Massachusetts Department of Public Health.
Does an external review cost anything?
The first $25.00 of the cost of the external review must be paid by the insured. The fee may be waived in cases of financial hardship. The remainder of the cost of review is paid by the health plan.
How long does an external review take?
External review agencies have 60 business days to make a determination. The 60-day period begins on the day the external review agency receives the request for external review from the Massachusetts Department of Public Health. The review agency may extend the time period for making a decision 15 additional business days if it needs additional time. However, if a physician certifies that an expedited review is necessary because a delay in providing the requested services would pose a serious and immediate threat to your health, the external review agency must render a decision in five business days.
Who conducts the external review?
The Massachusetts Department of Public Health contracts with three external review agencies: The Center for Health Dispute Resolution (CHDR), and the Island Peer Review Organization (IPRO), both located in New York, and Hayes Plus, located in Pennsylvania. The reviews are conducted by independent experienced physicians or other health care professionals from all over the United States who typically treat the health care conditions under review.
Does my health plan have to abide by the decision?
Yes. By law, external review decisions are binding.
How can I obtain a copy of an external review application?
Your health plan must explain the procedures for requesting an external review and include the external review forms whenever it issues a final adverse determination. You can also request a copy of an external review application from the Office of Patient Protection at 1-800-436-7757 or download the form from its website at
http://www.state.ma.us/dph/opp.
Can I participate in the external review?
The external review is a paper review, i.e., the independent physician or other professional reviews the medical records of the case. There is no hearing or other proceeding. If you have information that you want the reviewer to consider, it is important that you provide this information with your request for external review.
Does my health plan have to continue my coverage during the external review?
The law permits an insured to ask the external review agency to order continuation of coverage or treatment where a physician certifies that substantial harm to the patient's health may result if the coverage is not continued. This request must be made by the end of the second business day following the insured's receipt of the final adverse determination. Additionally, the treatment must have been initially authorized by the health plan and not terminated because of a specific time or episode-related exclusion in the contract. If the external reviewer orders continuation, the health plan must continue to pay for the coverage during the external review.