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Section 10: Appeals, Inquiries, and Grievances

This section describes our processes for listening to any problems you have that relate to the Plan or our members.

Clinical Right of a Provider to Discuss an Adverse Action or Adverse Determination. You may request to speak with a Plan medical director when a service has been denied or limited. All requests should be sent to us in writing to the attention of the medical director or his/her designee, with any additional clinical information that was not previously provided or used in our decision; this information should be received by the medical director prior to the discussion. Call our provider line at 1-888-566-0008, and select the appropriate department based on the type of service to be discussed (i.e., Medical Prior Authorization department, Care Management department, or Pharmacy department).

Provider Administrative Appeal of a Previously Denied Claim
If you wish to appeal a claim we have denied, submit a Provider Administrative Appeal form in writing to our Claims Resolution Unit. See section 15 for a sample of this form. If you have a question about an Administrative Appeal, call the provider line at 1-888-566-0008 and select option 2 to speak with a Claims Resolution Unit representative. Staff is available from 8:30 a.m. to 5 p.m., Monday through Thursday and Fridays from 8:30 a.m. to 3:30 p.m. (except holidays).

10.1 Overview

We have processes for receiving and promptly resolving member inquiries, grievances, and appeals, as well as provider requests for clinical reconsiderations of member responsibility denials and administrative appeals (provider appeals). The member appeals process includes the right of a member, or person acting on behalf of the member (Authorized Representative) to use our member appeals and grievances processes. All references to the Office of Medicaid Board of Hearings (BOH) refer to external appeals for MassHealth members. Commonwealth Care and Commercial plan members must pursue external appeals via the Office of Patient Protection. Since member/consumer protections (inquiries, grievances and appeals) differ among MassHealth, Commonwealth Care, and the Commercial plans, this manual section delineates MassHealth, Commonwealth Care and Commercial plan requirements.

For MassHealth, section 10.2.5 outlines the process you must follow when you want to discuss an Adverse Action (i.e., a denial or limited authorization of requested services, or the reduction, suspension, or termination of a previous authorization for a service) with a Plan medical director. Section 10.4 includes guidelines on a providers’ clinical right to discuss an adverse action. Section 10.5 describes the provider administrative appeal process.

10.2 MassHealth Appeals: Related Definitions

Below are some definitions useful to understanding our processes for certain inquiries, grievances, appeals and other MassHealth-related communications. For example, you might find these definitions helpful for:

  • Provider reconsideration requests
    • Clinical right to discuss an Adverse Action
  • Provider appeals
    • Administrative appeal of a previously denied claim (level one and level two)
  • Member inquiries
  • Member grievances
  • Member appeals
    • Standard appeal (level one and level two)
    • Expedited appeal (level one)
    • Medicaid Board of Hearings (BOH) appeal

10.2.1 Administrative Appeal

An administrative appeal is a written request made by a provider to the Plan for reconsideration of a denied claim or retrospective review for authorization after services have been rendered. These reviews include, but are not limited to, evaluating a claim denial for clinical editing, late submission or unauthorized services (e.g., failure to request Plan authorization). Administrative appeals do not include corrected claims, adjustments or claim resubmissions.

10.2.2 Administrative Appeals Committee

The Administrative Appeals committee is an internal committee composed of Plan managers who are responsible for reviewing level two administrative appeals. The Administrative Appeals committee renders a final decision, in writing, to the provider with an explanation of the decision.

10.2.3 Authorized Representative

An Authorized Representative is any individual that the Plan can document has been authorized by the member, in writing, to act on the member’s behalf with respect to a grievance, internal appeal or BOH external appeal. This authorization may remain permanently on file, but can be revoked at any time by the member. An Authorized Representative may also include the legal representative of a deceased member’s estate. Providers may act as Appeal Representatives, but cannot independently bring standard internal or BOH external appeals. You may request an expedited appeal without the written consent of the member. An Authorized Representative may be a family member, agent under a power of attorney, health care agent under a health care proxy, a healthcare provider, attorney or any other person appointed, in writing, to represent the member in a specific grievance or appeal. We may require documentation that an Authorized Representative meets one of the above criteria.

10.2.4 Appeals and Grievances Specialist

Our Appeals and Grievances Specialist is responsible for coordinating, investigating, documenting and resolving all appeals and grievances. For member appeals, this Specialist acts as a liaison between the Plan and Office of Medicaid's Board of Hearing for External Review Appeals.

10.2.5 Adverse Action

An adverse action is an occurrence that falls into one of the following categories:

  • The failure of a provider to deliver Plan-covered services in a timely manner in accordance with the access to care guidelines and waiting time standards
  • A Plan denial or limited authorization of a requested service, including the determination that a requested service is not a covered service
  • The Plan reduction, suspension or termination of a previous authorization for a service
  • The Plan’s failure to act within the required timeframes described in the utilization management timeline policy in section 3
  • The Plan’s failure to act within the required timeframes for reviewing an internal appeal and issuing a decision
  • The denial, in whole or in part, of payment for a service, where coverage of the requested service is at issue. Procedural denials for requested services do not constitute Adverse Actions. These include but are not limited to denials due to the provider’s failure to:
    • follow the Plan prior authorization procedures
    • follow Plan referral rules
    • file a timely claim
    • follow other Plan guidelines

10.2.6 Board of Hearings (BOH)

The Board of Hearings (BOH) is within the Executive Office of Health and Human Services’ Office of Medicaid and is responsible for reviewing external member appeals.

10.2.7 Board of Hearings (BOH) Appeal

An external appeal available to members who have exhausted our internal appeals process and are requesting an external review. A BOH appeal is a written request to BOH by a member or the member's Authorized Representative to review a final, internal appeal decision made by the Plan.

10.2.8 Continuing Services

Covered services that we previously authorized and are the subject of an internal appeal or BOH appeal involving a decision by the Plan to terminate, suspend or reduce the previous authorization. We provide continuing services pending the resolution of the internal appeal or a BOH appeal. Continuing services will be provided if the request is made within 10 calendar days from the date of the Adverse Action.

10.2.9 Date of Action

The effective date of an Adverse Action.

10.2.10 Expedited Internal Appeal

An internal appeal that has been expedited because the Plan determines, or a physician on behalf of a member asserts, that taking the time for a standard resolution could seriously jeopardize the member's life or health, or the member's ability to attain, maintain, or regain maximum function. There is only one level of internal review for expedited appeals.

10.2.11 Final Internal Appeal

A final internal appeal is a second-level review of a standard internal appeal; or, for a member who waives the second-level internal appeal, it is the first-level Plan review of a standard internal appeal.

10.2.12 First-Level Standard Internal Appeal

The first-level review of a request by a member or member's Authorized Representative for review of an Adverse Action.

10.2.13 Grievance

A grievance is any expression of dissatisfaction by a member or an Authorized Representative about any action or inaction by the Plan other than an Adverse Action. Possible subjects for grievances include, but are not limited to, quality of care of services provided, aspects of interpersonal relationships such as rudeness of a provider, office staff or Plan employee, or failure to respect the member’s rights.

10.2.14 Inquiry

An inquiry is any oral or written question by a member to the Plan’s Member Services department regarding an aspect of the Plan’s operations that does not express dissatisfaction about the Plan.

10.2.15 Provider

Provider refers to an appropriately credentialed and licensed individual, practitioner, physician, healthcare professional, vendor, or facility, agency, institution, organization or other entity that has an agreement with the Plan for the delivery of services. This manual uses the term “you” synonymously with “provider.”

10.3 Commonwealth Care and Commercial Plans Appeals: Related Definitions

Below are definitions to be used for the Commonwealth Care and Commercial plans sections of this manual.

10.3.1 Administrative Appeal

An administrative appeal is a written request made by a provider to the Plan for reconsideration of a denied claim, or retrospective review for authorization after services have been rendered. The review includes, but is not limited to, evaluating a claim denial for clinical editing, late submissions, or unauthorized services (e.g., failure to request Plan authorization). Administrative appeals do not include corrected claims, adjustments or claim resubmissions.

10.3.2 Administrative Appeals Committee

The Administrative Appeals committee is an internal committee comprised of Plan managers who are responsible for reviewing level two administrative appeals. The Administrative Appeals committee renders a final decision, in writing, to the provider with an explanation of the decision.

10.3.3 Authorized Representative

An Authorized Representative is any individual that the Plan can document has been authorized, in writing, by the member to act on the member’s behalf with respect to all grievances, internal appeals or external appeals. Such standing authorization may be revoked by the member at any time. A member may verbally authorize a practitioner to act on his/her behalf to initiate an appeal, and you may request an expedited appeal without the written consent of the member. A member may be represented by anyone he/she chooses, including an attorney or a provider. An Authorized Representative may be a family member, agent under a power of attorney, healthcare agent under a healthcare proxy, a healthcare provider, attorney or any other person appointed in writing to represent the member in a specific grievance or appeal. We may require documentation that an Authorized Representative meets one of the above criteria.

10.3.4 Appeals and Grievances Specialist

Our Appeals and Grievances Specialist is responsible for coordinating, investigating, documenting and resolving all appeals and grievances. For member appeals, the specialist acts as a liaison between the Plan and the Office of Patient Protection for External Review Appeals.

10.3.5 Appeal

An appeal is a formal complaint by a member or member's Authorized Representative about a denial of coverage. There are two types of denials which may be appealed:

  • Benefit denial – A Plan decision, made before or after the member has obtained services, to deny coverage for a service, supply or drug that is specifically limited or excluded from coverage in the Commonwealth Care or Commercial plan member's respective Evidence of Coverage (EOC).
  • Adverse determination – A Plan decision, based on a review of information provided, to deny, reduce, modify or terminate an admission, continued inpatient stay or the availability of any other healthcare services, for failure to meet the requirements for coverage based on medical necessity, appropriateness of healthcare setting and level of care or effectiveness. These are often known as medical necessity denials because in these cases the Plan has determined that the service is not medically necessary for the member.

10.3.6 Final Adverse Determination

An Adverse Determination made after a member has exhausted all remedies available through the Plan's internal appeals process.

10.3.7 Grievance

A grievance is any formal complaint, oral or written, submitted by a member or member's Authorized Representative, regarding:

  • Plan administration (how the Plan is operated): Any action taken by a Plan employee, any aspect of the Plan's services, policies or procedures, or a billing issue.
  • Quality of care: The quality of care a member received from one of our participating providers.

10.3.8 Inquiry

An inquiry is a communication by or on behalf of a member to the Plan that has not been the subject of an adverse determination and that requests redress of an action, omission or policy of the Plan. It is any communication by a member to the Plan asking us to address a Plan action, policy or procedure. It does not include questions about adverse determinations, which are Plan decisions to deny coverage based on medical necessity.

10.3.9 Office of Patient Protection (OPP)

The office within the Commonwealth’s Department of Public Health established by M.G.L. c. 111 §217 responsible for the administration and enforcement of M.G.L. c. 176O §§ 13, 14, 15 and 16 and 105 CMR 128.000.

10.3.10 Provider

Provider refers to an appropriately credentialed and licensed individual, practitioner, physician, healthcare professional, vendor, or facility, agency, institution, organization, or other entity that has an agreement with the Plan for the delivery of services. This manual uses the term “you” synonymously with “provider.”

10.4 Clinical Right of a Provider to Discuss an Adverse Action/Determination

Our Medical/Surgical Prior Authorization, Pharmacy Prior Authorization and Hospital Care Coordination staffs are responsible for processing pre authorization (pre-service) concurrent and retrospective authorization requests. The staff refers all provider requests that do not meet medical necessity review criteria, level-of-care criteria, or medical policy to a Plan medical director or clinical licensed pharmacist for pharmacy requests for review and determination. Adverse Actions/ Determinations (i.e., authorization denials) resulting from a determination of medical appropriateness or necessity are made by a Plan medical director or clinical pharmacist for pharmacy requests.

At your request and with appropriate documentation, a Plan medical director, clinical pharmacist or designee will be available to discuss the adverse action/determination with you. You may submit, in writing, additional clinical information to the medical director or clinical pharmacist who was not previously provided or used in the decision. This process is not required prior to the member or Authorized Representative filing a clinical appeal. The medical director or clinical pharmacist will communicate any recommendation(s) to you for alternative care or an alternative treatment plan for the member, when appropriate.

10.5 Provider Administrative Appeal

This section applies to MassHealth and Commonwealth Care and Commercial plans.

You may submit an administrative appeal to the Plan if you are requesting that a previously denied claim be overturned due to circumstances outlined below. You may request that we review and reconsider an authorization or claim that was denied for an administrative reason rather than for medical necessity of services. The administrative appeal process is only applicable to claims that have already been processed and denied. An administrative appeal can not be requested for services rendered to a member who was not eligible on the date(s) of service, or for benefits that are not administered or covered by the Plan. We provide a thorough, timely and unbiased review of an administrative appeal for:

  • Claims received outside of the timely filing limit
  • Claims denied for not following the Plan authorization/referral process
  • Member eligibility limitation
  • Member benefit limitation
  • Coding or clinical edit denials

An administrative appeal does not include:

  • Standard and expedited internal member appeals (see sections 10.6.3 and 10.6.4)
  • Claim adjustment or corrected claim - Any previously filed claim that is resubmitted with information that has been changed by the provider (see Section 2.13)
  • Claim resubmission - Any previously filed claim that is resubmitted due to incorrect claim processing by the Plan (see section 2.14)
  • Coordination of benefit, motor vehicle accident, and workers compensation appeal (see section 2.7)

10.5.1 Level One and Level Two Administrative Appeals

We offer two levels of internal administrative review to providers. If the initial review (level one) results in an administrative denial, you have the opportunity to file a second administrative appeal (level two) to the Plan. The Administrative Appeals committee will automatically review all level-two appeals. All second level administrative appeal decisions rendered by the Administrative Appeals committee are final decisions by the Plan.

10.5.2 Information Required for Administrative Appeals

10.5.2.1 Required Documentation

To request an administrative appeal, you must submit the following information within the applicable filing timeframe specified in section 10.5.3.

  • You must complete and submit a completed Request for Claim Review Form. See section 15)
  • The Administrative Appeal request form must include an explanation describing the issue related to the administrative appeal submission, and the justification that would allow us to overturn the denial.
  • You must submit to the Plan the required documentation and relevant information related to the administrative appeal (as specified in section 10.5.4).

Mail the documents and information to the following address:

BMC HealthNet Plan
Claims Resolution Unit
Attn: Provider Appeals
P.O. Box 55282
Boston, MA 02205.

The review of a claim submitted as an appeal will be rejected if the claim is more appropriately categorized as a claim resubmission or correction. We will reject and return all incomplete appeal submissions.

10.5.2.2 Required Data Elements for Administrative Appeals

The following data elements must be present on the Administrative Appeal Request form and must be legible:

  • Provider name
  • Plan-assigned provider identification (ID) number/NPI
  • Contact name
  • Contact telephone number
  • Member name
  • Member ID number
  • Claim number
  • Date of service
  • Procedure code being appealed
  • Charge amount
  • Total claim charges
  • Denial code

10.5.2.3 Recommended Documentation for Administrative Appeals

To avoid processing delays, we recommend that you submit as much documentation as possible that supports the appeal when submitting an administrative appeal. Additionally, each denial requires specific documentation to substantiate an appeal. Examples of such documentation may include copies of one or more of the following:

  • Original explanation of payment (EOP) or remittance advice
  • Proof of timely claims submission
  • Plan reference number
  • Surgical/operative notes
  • Office visit notes
  • Pathology reports
  • Medical invoices (e.g., invoices for durable medical equipment or pharmaceuticals)
  • Medical record entries

10.5.3 Filing an Administrative Appeal

Administrative appeals must be filed with the Plan within 150 calendar days from the original denial date and no later than 300 calendar days from the date of service. The filing limit for claims submission to the Plan is 150 calendar days from either the date of service, the date of hospital discharge or, in the case of multiple insurers, the date of the primary insurer’s explanation of benefits (EOB). Retrospective adjustments (beyond the maximum 300 calendar days) will be denied or considered at the Plan’s discretion. An administrative appeal filed after these timeframes will be denied, and the Plan will be held harmless.

You must submit an affidavit or statement and any additional information identifying details that caused the delay in filing the claim, the exception being requested, and verification that the delay was not caused by neglect, indifference, or lack of diligence by the provider or the provider’s employee or agent. The individual who knows the facts of the case must make the affidavit or statement. We consider exceptions to the claims filing limit only if specific situations exist, such as:

  • The delay was due to a catastrophic event that substantially interfered with normal business operations of the provider, or damage or destruction of the provider’s business office or records by a natural disaster, including but not limited to fire, flood, or earthquake; or damage or destruction of the provider’s business office or records by circumstances that were clearly beyond the control of the provider, including but not limited to criminal activity. Providers requesting an extension based on a catastrophic event must submit independent evidence of loss, police report, or fire report substantiating the exception due to damage, destruction, or criminal activity.
  • There was a delay or error in the eligibility determination of a member or delay because of erroneous written information from the Plan, another state agency, or health insuring agent. A provider requesting an extension based on this exception must submit the written document that contains the erroneous information or an explanation of the delayed information.
  • There was a delay because of electronic claim or system implementation problems. Providers requesting an extension based on this exception must submit a written statement of the problems encountered and provide supporting documentation. This statement should include a detailed statement explaining why alternative billing procedures were not initiated after the delay in repairs or system implementation was known.

Send any administrative appeals to:

BMC HealthNet Plan
Claims Resolution Unit
Attn: Provider Appeals
P.O. Box 55282
Boston, MA 02205

10.5.4 Documentation Checklist Sorted by Type of Administrative Appeal

10.5.4.1 Reimbursement Appeal

  • You must submit a written explanation of the requested change(s) on the Request for Claim Review Form; (see section 15).
  • You must attach the remittance advice and identify the claim the Plan should review.
  • You must attach all supporting documentation in the form of invoices, operative notes, office notes, or any necessary medical record information.

10.5.4.2 Claim Denied for Lack of Plan Authorization

  • You must submit a completed Request for Claim Review Form detailing all pertinent information with the necessary clinical documentation; (see Request for Claim Review form in section 15).
  • Attach a copy of the claim and the remittance advice.
  • Authorization-related appeals must demonstrate medical necessity and identify any additional clinical information to the Plan that was not previously provided or used in the initial decision.
  • If prior authorization was required but not obtained, you must supply a written explanation of an extenuating circumstance that prevented you from contacting us for prior authorization or extending an existing authorization to cover the date(s) of service for a member’s treatment.
  • If prior authorization was required and obtained, you must supply proof to the Plan that you followed the Plan’s prior authorization procedure. Proper supporting documentation includes a copy of your original information faxed/submitted to the Plan and relevant medical records. Also, please include the reference number received verbally or in writing from the Plan.

We review claims denied for lack of authorization in these situations:

  • The member was added retrospectively to the Plan after the service was rendered.
  • The member was added retrospectively to the Plan during a course of continuing treatment.
  • The member has been referred for same day services.
  • Gaps in authorization exist for ongoing or continuing outpatient services and when extenuating circumstances exist.
  • A service was provided (e.g. by a non-participating provider) that was urgent or emergent in nature and the service is covered by the Plan. However, there was an auto or manual administrative denial issued. Submit the medical documentation that supports the justification that the requested service was either urgent or emergent.

Other cases that support extenuating circumstances and retrospective review are appropriate.

If one of these criteria is met, we will review the case and, if approved, we will adjust the claim. Only those services that meet medical necessity criteria which were in place on the date of service will be approved. This applies to all provider requests that do not meet medical necessity review criteria, level-of-care criteria, or medical policy to a Plan medical director. When the service is determined to be not medically necessary, the claim denial will be upheld.

10.5.4.3 Claim Denied for Submission over the Filing Limit

An administrative appeal submitted to us due to a claim denial for filing limit violations needs to include a completed Request for Claim Review Form (see section 15) and proof of a prior claim submission. The administrative appeal must include one of the following or the appeal will be returned unprocessed:

  • If the initial claim submission is after the filing limit and the circumstance for the late submission is beyond your control, you may appeal by sending a letter documenting the reason(s) why the claim could not be submitted within the contracted filing limit. Please include the original claim form. You must send us the appeal within the timeframe specified in section 10.5.3.
  • If the member did not identify him/herself as a Plan member, you must supply proof to the Plan that the member had been billed within our timely filing limit.

A provider who submits paper claims must attach the following to be considered acceptable proof of prior submission.

  • Computer printout of patient account ledger
  • EOB from primary insurer
  • Proof that another insurance carrier was billed

A provider who submits electronic claims (either through a clearinghouse or directly to the Plan) must attach the applicable electronic data interchange (EDI) transmission report. The EDI transmission report will provide proof of prior-submission and indicate that we did not reject the claim.

Method of EDI Submission EDI Transmission Report(s) EDI Message
WebMD Submitter Daily Summary and Provider Daily Summary Claims submitted to WebMD.
Claims rejected at WebMD with reject reason.
Medunite Claims Audit Report Claims accepted or rejected at Medunite with reject reason.
SSI Report Type Level 1 – EDI Data Center Confirmation
Directly to the Plan Claims Acceptance Acknowledgement Claims accepted or rejected at the Plan with reject reason.

NEHEN (New England Health EDI Network) has been added as a vendor specializing in electronic solutions.

10.5.4.4 Claim Denied Because Member Ineligible on the Date of Service

  • You must submit a written explanation of the requested change(s) on a completed Request for Claim Review Form. (See section 15.1.)
  • If a member becomes retroactively eligible or loses Plan eligibility and is later determined to be eligible, the 150-calendar day timely filing deadline begins on the date the member is enrolled into the Plan.
  • Attach the remittance advice and written evidence that the member was eligible for the time period covered by the date(s) of service. A printout from MassHealth EVS or a printout from another agency or organization that is approved to provide eligibility information can suffice as written evidence of eligibility.

10.5.4.5 Claim Denied for Coding and Clinical Editing

  • You must submit a completed Request for Claim Review form (see section 15.1.) detailing all pertinent information, including RA denial code and identify the specific procedure code(s) being appealed, and provide the necessary clinical documentation; E/M encounters require documentation of history, exam, and medical decision-making; documentation must support the levels billed. If you bill for two separate services or procedures, the documentation for each service must be able to stand alone and support that charge. This includes:
    • The reason for the encounter clearly stated
    • Appropriate history and physical examination
    • Review of any labs, X-rays and other ancillary services
    • The reason for and results of diagnostic tests
    • Relevant health risk factors
    • The member’s progress, including response to treatment, change in treatment, and member’s noncompliance
    • Assessment plan of care including treatments and medications (specify frequency and dosage), referrals and consults, member/family education, specific instructions for follow-up, and discharge summary and instructions
  • You must attach a copy of the claim and the remittance advice.

10.5.5 Administrative Appeals Committee

The Administrative Appeals committee includes Plan representatives from the following areas: Health Services, Contracting and Network Management, Claims and regional offices. We establish guidelines for making appeal determinations; the guidelines can only be modified by the committee with final approval from the Plan’s executive director. These guidelines include specific claim denial situations that may be appealed, the supporting rationale to either uphold or overturn a denial, and the acceptable documentation requirements for an administrative appeal. In all cases, you must submit adequate supporting documentation for the appeal request. If the administrative appeal is approved, payment will be issued and an EOB/RA will serve as notification.

10.5.6 Timeframes for Administrative Appeal Determination

An appeals coordinator ensures all necessary information is attached to the appeal. Incoming appeals are date stamped, and assigned a document control number. The appeal is sent out to a third party vendor for imaging, the third party vendor returns image via an electronic file within 72 hours from the date of shipment. You can call the Claims Resolution Unit and speak with a representative to confirm receipt or to verify the status of your appeal. Once we have reached a decision, we will send you a written notice of determination and the reason(s) for the determination. An administrative appeal decision is based on the information available at the time of the review and will usually be rendered within 30 calendar days of receipt of the appeal.

10.6 MassHealth Member Inquiries, Grievances and Appeals

We have an effective process to respond to member inquires, resolve member grievances, and address member appeals in a timely manner. If the inquiry has to do with medical necessity or a service coverage issue, the member is offered assistance and is informed of the appeals process. If the inquiry cannot be resolved immediately or within one business day, the issue is addressed as a grievance. A member or member's Authorized Representative has the right to file a grievance or appeal with the Plan or MassHealth. You may assist in resolving a member issue by furnishing documentation and other information that we request, and may be appointed as an Authorized Representative by the member to act on a member’s behalf regarding a grievance, internal appeal or BOH appeal.

A member or member's Authorized Representative may submit three types of appeals for Adverse Actions related to medical/surgical and/or pharmacy services covered by the Plan:

  • Standard internal appeal—Level one and level two
  • Expedited internal appeal—Level one only
  • BOH appeal

An appeal of an Adverse Action is a standard internal appeal or an expedited internal appeal filed with the Plan by a member or member's Authorized Representative. An external review appeal is directed to the BOH. Member appeals must be submitted to the Plan within 30 calendar days of the notice of Adverse Action to the Member. We may reject as untimely any Plan appeals submitted later than 30 calendar days after the notice of an Adverse Action.

10.6.1. How a Member Submits an Inquiry, Grievance or Appeal

When a member has a concern about the care, service or access to service provided by the Plan or a participating provider, the member or member's Authorized Representative may submit an inquiry, grievance or appeal in any of the following ways:

  • The member or member’s Authorized Representative may file an oral appeal or grievance by calling our Member Services department at 1-888-566-0010 or 1-866-765-0055 (TTY/TDD). Use of language services is free of charge to the member or member’s Authorized Representative. See section 12 for information on the Member Services department, including hours of operation and services provided.
  • The member or member’s Authorized Representative may make oral inquiries by calling the Member Services department as well.
  • If a minor is able, under law, to consent to a medical procedure, that minor can request an appeal of the denial of such treatment without parental/guardian consent.
  • The member or member's Authorized Representative may send written appeals and/or grievances to us at:
    BMC HealthNet Plan
    Member Appeals and Grievances
    Two Copley Place, Suite 600
    Boston, MA 02116
  • The member or member's Authorized Representative may submit a grievance or appeal to a Plan representative in person at a Plan office location during regular business hours, 8:30 a.m. to 5 p.m., Monday through Friday (except holidays).
  • The member or member's Authorized Representative may call a health benefits advisor at the MassHealth Customer Service Center. The MassHealth Customer Service Center is available Monday through Friday, 8:00 a.m. to 5 p.m. (except holidays). See section 1 for the telephone numbers for MassHealth.
  • The member or member's Authorized Representative may submit an external appeal request to the BOH after exhausting the Plan’s internal appeal process and only a final internal appeal decision has been rendered by the Plan. Section 10.6.5 offers an overview of the BOH appeals process.

We will send written acknowledgement of the receipt of any grievance or internal appeal to members and/or Authorized Representatives, if applicable, within one business day of receipt by the Plan.

We will complete the resolution of grievances and send written notice to affected parties, no more than 30 calendar days from the date the Plan received the Grievance. See sections 10.6.3 through 10.6.5 for notice of resolution for appeals.

We will provide instructive materials and forms to assist a member who submits a grievance or appeal. If the member requests it, we will give him or her reasonable assistance completing the forms and following procedures applicable to the internal appeals process. This includes, but is not limited to, providing interpreter services free of charge and toll-free numbers with TTY/TDD and interpreter capability.

10.6.2 Monitoring Member Appeals

We maintain reports of all Member appeals (including both internal appeals and external appeals submitted to the BOH). These reports include the following information:

  • Type and nature of the appeal
  • How each appeal was addressed
  • Outcome of the appeal
  • What, if any, corrective action was taken related to the appeal
  • The provider involved in the appeal
  • If the service was denied or approved after review of the appeal

We review these data and our appeals policies annually and make any necessary modifications or improvements.

10.6.3 Standard Internal Appeal

The Plan offers two levels of internal review for standard appeals. First and second level reviews are conducted by healthcare professionals who have the appropriate clinical expertise in treating the medical condition, performing the procedure, or providing the treatment that is the subject of the Adverse Action, and who have not been involved in any prior review or determination of the particular internal appeal and who are not the subordinate of someone who was involved. During the appeal review process, the Plan will consult, if appropriate, with same or similar board-certified specialty providers who typically treat the medical condition, perform the procedure or provide the treatment involved in the appeal. Information regarding the internal appeal process and the BOH appeal process is included in any notice following the resolution of an Adverse Action or internal appeal. Appeals must be filed by the member or member's Authorized Representative within 30 calendar days of the notice of the Adverse Action or notice of our decision following an appeal. We will not take punitive action against providers who support a member's internal appeal.

Our standard internal appeal process and written notice to affected parties will conclude no more than 40 calendar days from the date we received the member’s request for a first-level internal appeal (unless the timeframe is extended). This timeframe excludes the time the member took to file the second-level internal appeal.

We will allow a member or member's Authorized Representative, before and during the internal appeals process, the opportunity to examine the member's case file, including medical records, and any other documentation and records considered during the internal appeals process.

We will also allow reasonable opportunity for a member or member's Authorized Representative to present evidence and allegations of fact or law in person as well as in writing.

The timeframe for the standard appeal may be extended for up to five calendar days if the member or member's Authorized Representative requests the extension, or the Plan can justify (to MassHealth, upon request) that:

  • The extension is in the member’s interest; and
  • There is a need for additional information, where there is a reasonable likelihood that receipt of this information would lead to approval of the request, if received; and this outstanding information is reasonably expected to be received within five calendar days.

For any extension not requested by the member or member's Authorized Representative, the Plan will provide the member or member's Authorized Representative with written notice of the reason for the delay. The member or member's Authorized Representative has the right to file a grievance regarding an extension decision made by the Plan. The member or member’s Authorized Representative can request a five day extension at each level of standard internal appeal. The Plan can have only one extension.

We will provide the member with continuing services, if applicable, pending resolution of the first or second-level review of an internal appeal, if the member submitted the request for the first or second level internal appeal within 10 calendar days of the Adverse Action, unless the member specifically indicates that he or she does not want to receive continuing services. If the decision is to uphold the Adverse Action denial, the member may have to pay MassHealth for the cost of the continuing services.

10.6.4 Expedited Internal Appeal

A member or member's Authorized Representative may request an expedited internal appeal after receiving notification of an Adverse Action for urgent or time-sensitive care. See section 10.2.10 for a definition of an urgent or time-sensitive case eligible for an expedited appeal. We do not require written permission from the member for providers to file expedited appeals on the member's behalf, and the Plan will not take punitive action against providers who request an expedited resolution on behalf of a member.

We offer one level of internal review for an expedited appeal. The review is conducted by a healthcare professional who has the appropriate clinical expertise in treating the medical condition, performing the procedure, or providing the treatment that is the subject of the adverse action. A determination will be made within 72 hours of the receipt of the expedited internal appeal unless this timeframe is extended as outlined below.

We will allow reasonable opportunity for a member or member's Authorized Representative to present evidence and allegations of fact or law in person as well as in writing. We will also remind a member or member's Authorized Representative of the limited time available for this opportunity In the case of an expedited appeal.

We may reject the request of a member or member's Authorized Representative for an expedited appeal. In the event the request is rejected, the Plan will:

  • Transfer the internal appeal to the timeframe for standard internal appeal resolution, and
  • Make reasonable efforts to give the member or member's Authorized Representative oral notice of the denial, and will send written notice within two calendar days.

We may only reject a provider's request on behalf of a member for an expedited appeal if the Plan determines that the request is unrelated to the member's health condition.

The timeframe for the expedited appeal determination may be extended for up to 14 calendar days if the member or member's Authorized Representative requests the extension, or if the Plan can justify to MassHealth, upon request that:

  • The extension is in the member’s interest; and
  • There is a need for additional information where there is a reasonable likelihood that receipt of this information would lead to approval of the request, if received; and this outstanding information is reasonably expected to be received within 14 calendar days.

For any extension not requested by the member or member's Authorized Representative, the Plan will provide the member or member's Authorized Representative with written notice of the reason for the delay. The member or member's Authorized Representative has the right to file a grievance regarding an extension decision made by the Plan.

We will provide the member with continuing services, if applicable, pending resolution of the expedited appeal if the member submitted the request for the expedited appeal within 10 calendar days of the Adverse Action, unless the member specifically indicates that he or she does not want to receive continuing services.

We notify the member, member's Authorized Representative (if applicable) and treating provider by telephone and in writing of our decision related to the expedited internal appeal. A member or member's Authorized Representative may submit an external appeal request to the BOH after the resolution of an expedited internal appeal with the Plan.

10.6.5 Board of Hearings (BOH) Appeal

A member may request an external appeal review with the BOH after we have rendered an internal appeal decision, standard or expedited. The member may file a hearing request within 30 calendar days of the Plan’s notification of a standard internal appeal denial. Requests for expedited hearings must be filed within 20 calendar days from the date of the Plan’s expedited internal appeal denial. We will include the BOH Fair Hearing Application and other instructive materials that the member or member's Authorized Representative will need to complete to request a fair hearing with the BOH. We will assist the member in submitting the BOH appeal request and completing the BOH form if an external appeal is requested by the member or member's Authorized Representative.

If the member or member's Authorized Representative does not understand English and/or is hearing or sight impaired, the BOH will make sure that an interpreter and/or assistive device is available at the hearing.

We will make best efforts to ensure that a provider, acting as an appeal representative, submits all applicable documentation to the BOH, the member and the Plan within five business days prior to the date of the hearing, or if the BOH appeal is expedited, within one business day of being notified by the BOH of the date of the hearing. Applicable documentation will include, but not limited to, any and all documents that will be reviewed upon at the hearing.

We will provide the member with continuing services, if applicable, pending resolution of the BOH appeal if the member or member's Authorized Representative submits the request for the BOH appeal within 10 calendar days from the date of the decision on the member's first or second level standard internal appeal of expedited internal appeal, unless the member specifically indicates that he or she does not want to receive continuing services. If the BOH appeal decision is to uphold the Plan's denial of coverage, the member may have to pay MassHealth for the cost of the continuing services.

We will allow a member or member's Authorized Representative access to the member's appeal files during the BOH appeal process, and we will implement the BOH appeal decision immediately if our decision is overturned.

10.6.6 Member or Authorized Representative Pharmacy Copayment Appeal Process

A member or member's Authorized Representative may submit a pharmacy copayment appeal to the Plan if he/she believes that the copayment cap is met earlier than documented by the Plan. If the member does not agree with our decision, the member or member's Authorized Representative may appeal to the Plan using the standard internal appeal process in section 10.6.3 (or the expedited internal appeal process in section 10.6.4 if necessary criteria are met). A member or member's Authorized Representative may also request another level of appeal through the BOH. See section 10.6.5 for a description of the BOH appeal process.

10.7 Commonwealth Care and Commercial Plans Member Inquiries, Grievances and Appeals

10.7.1 Internal Inquiry Process

An inquiry is any communication the member makes to the Plan asking us to address a Plan action, policy or procedure. An inquiry is a communication by or on behalf of a member to us that has not been the subject of an adverse determination and that requests redress of an action, omission or policy of the Plan. It does not include questions about adverse determinations, which are Plan decisions to deny coverage based on medical necessity.

The internal inquiry process is an informal process used to resolve most inquiries. Members or their Authorized Representatives can initiate this process by calling the Member Services department at 1-877-957-5300 (Commonwealth Care members) or 1-877-492-6967 (Commercial plans members).

The internal inquiry process is not used to resolve concerns about the quality of care received by members or an adverse determination (coverage denial based on medical necessity). If a concern involves the quality of care received from a provider, Member Services will refer the concern directly to its internal grievance process. If a concern involves an adverse determination, Member Services will refer the concern directly to our internal appeals process (see below).

The Member Services staff will review and investigate inquiries and respond to a member or Authorized Representative by phone within three working days. When communicating the findings, department staff will determine whether the member is satisfied with the outcome. If the member or the member's Authorized Representative is not satisfied, or the Plan was unable to resolve the inquiry within three working days, we will offer to start a review of the concern through our formal internal grievance or appeal process (see below). The process used depends on the type of inquiry. If a decision is made not to start a grievance or appeal during the Plan’s call with the member or Authorized Representative, the Plan will send the member or the Authorized Representative a letter explaining the right to file a grievance or appeal.

10.7.2 Internal Grievance Process

We do not use the internal grievance process to resolve complaints about a denial of coverage. We address complaints relating to Adverse Actions through the internal appeals process. We categorize internal grievances as follows:

Administrative Grievances (how the Plan operates): Grievances related to billing issues or a member’s dissatisfaction with our staff, policies, processes or procedure that have no impact on the member’s medical care or access to medical care.

Clinical Grievances (Quality of Care Grievances): Grievances relating to the healthcare and/or services that a member has received from a Plan participating provider or is trying to receive.

Expedited Clinical Grievances (Expedited Quality of Care Grievances): Grievances relating to clinical issues of an urgent nature such that it is deemed that a delay in the review process might seriously jeopardize:

  • the life and/or health of the member, and/or
  • the member’s ability to regain maximum functioning, or is an issue that poses an interruption in the ongoing immediate treatment of the member

The preferred way for a member or member's Authorized Representative to file a grievance is to put it in writing and send it to us by postal mail or electronically by fax. A grievance also may be delivered in person to one of the Plan’s offices or may be submitted orally by calling the Member Services department at 1-877-957-5300 (Commonwealth Care members) or 1-877-492-6967 (Commercial plans members). If the grievance is filed orally, the Appeals and Grievances Specialist will write a summary of their understanding of the grievance and send a copy to the member or member's Authorized Representative within 48 hours of receipt (unless the time limit is extended by mutual written agreement). This summary will serve as both a written record of the grievance as well as an acknowledgment of our receipt of it. These time limits may be extended by mutual written agreement.

Written grievances should include name, address, Plan ID number, daytime telephone number, detailed description of the grievance (including relevant dates and provider names), and any applicable documents that relate to the grievance (such as billing statements). Written grievances should be faxed to 617-897-0805 or mailed to:

BMC HealthNet Plan
Member Appeals and Grievances
Two Copley Place, Suite 600
Boston, MA 02116

A grievance may be filed any time within 180 days of the date of the applicable event, situation or treatment. We encourage the member or member's Authorized Representative to file grievances as soon as possible.

Once the written grievance is filed, we send a letter (“acknowledgement”) to the member or member’s Authorized Representative explaining that we have received the grievance. We send this letter within 15 working days of the receipt of the grievance.

If the grievance requires us to review medical records, a signed Authorization to Release Medical Records Form must be submitted to us. When signed by an Authorized Representative, appropriate proof of authorization to release medical information must be provided. If an Authorization to Release Medical Records Form is not included with the grievance, we will promptly send to the member or member's Authorized Representative a blank Authorization to Release Medical Records Form. If we do not receive this Authorization to Release Medical Records Form within 30 calendar days of the date of the grievance, we may respond to the grievance without having reviewed relevant medical information. In addition, if we receive the form but a provider does not give us the medical records in a timely fashion, we will ask the member or Authorized Representative to agree to extend the time limit for us to respond to the grievance. If the Plan cannot reach agreement on a timeline extension, we may respond to the grievance without having reviewed relevant medical information.

All grievances will be processed by an Appeals and Grievances specialist. Reviews will be performed by appropriate healthcare professionals who are knowledgeable about the type of issues involved in the grievance. Responses will be based on the terms of the Commonwealth Care or Commercial plans EOCs, the Plan’s clinical policies and guidelines, the opinions of the treating providers, the opinions of the Plan’s professional reviewers, applicable records provided by providers, and any other relevant information available to the Plan.

We will send a written response to the member or member’s Authorized Representative within 30 calendar days of receipt of the grievance. The 30 calendar day period begins as follows:

  • If the grievance requires the Plan to review medical records, the 30 calendar day period does not begin until the Plan receives a signed Authorization to Release Medical Information Form.
  • If the grievance does not require a review of medical records, the 30 calendar day period begins on the next working day following the end of the three working day period for processing inquiries through the internal inquiry process, if the inquiry was not addressed within that time period, or on the day the Plan was notified of the member’s lack of satisfaction with the response to the inquiry.

These time limits may be extended by mutual written agreement between the member or member's Authorized Representative and the Plan. Any extension will not exceed 30 calendar days from the date of the mutual agreement. If the Plan does not respond to a grievance that involves benefits within the timeframes described in this section, including any mutually agreed upon written extension, the grievance will be deemed decided in the member’s favor. Our written response to a grievance will describe other options, if any, for further Plan review of a grievance.

We will not consider a grievance received until it is actually received by the Plan at the appropriate address or telephone number listed. Members are entitled to free access to and copies of any of their medical information related to their grievance that is in the Plan’s possession and under the Plan’s control.

10.7.3 Member or Authorized Representative Commonwealth Care Pharmacy Copayment Grievance Process

A member or member's Authorized Representative may submit a pharmacy copayment grievance to the Plan if s/he believes that the copayment cap is met earlier than documented by the Plan. If the member does not agree with the Plan’s decision, the member or Authorized Representative may file a grievance with us using the internal grievance process. Finally, a member or Authorized Representative may appeal the pharmacy copayment cap to the Connector at:

Commonwealth Care Customer Service Center
P.O. Box 120089
Boston, MA 02112-9914
1-877-MA-ENROLL Fax: 1-877-623-2155
Business Hours: Monday-Friday, 8 a.m.-5 p.m.

10.7.4 Internal Appeals Process

An Appeal is a formal complaint by you, on behalf of a member, about a Benefit Denial, an Adverse Determination or a Retroactive Termination of Coverage – all as specifically defined as follows:

  • Adverse Determination: A Plan decision, based on a review of information provided, to deny, reduce, modify or terminate an admission, continued inpatient stay or the availability of any other healthcare services, for failure to meet the requirements for coverage based on medical necessity, appropriateness of healthcare setting and level of care, or effectiveness.  These are often known as medical necessity denials because in these cases the Plan has determined that the service is not medically necessary for you.
  • Benefit Denial:
    • A Plan decision, made before or after you have obtained services, to deny coverage for a service, supply or drug that is specifically limited or excluded from coverage in the Evidence of Coverage; or
    • A Plan decision to deny coverage for a service, supply or drug because you are no longer eligible for coverage under the Plan. (This means you no longer meet the Plan’s eligibility criteria.)
  • Retroactive Termination of Coverage: A retroactive cancellation or discontinuance of enrollment as a result of the Plan’s determination that: you have performed an act, practice or omission that constitutes fraud; or you have intentionally misrepresented a material fact with regard to the terms of the Plan.

The preferred way for a member or member's Authorized Representative to file an appeal is to put it in writing and send it to the Plan by postal mail or electronically by fax. The appeal may also be delivered in person to one of the Plan’s offices or may be submitted orally by calling the Member Services department at 1-877-957-5300 (Commonwealth Care members) or 1-877-492-6967 (Commercial plans members). If a written appeal has been filed, the Plan will send a letter (“acknowledgment”) to the member or member’s Authorized Representative explaining that the appeal has been received. We send this letter within 15 working days of receipt of the appeal. If the appeal is filed orally, the Appeals and Grievances Specialist will write a summary of the grievance and send a copy to the member or member's Authorized Representative within 48 hours of receipt (unless the time limit is extended by mutual written agreement). This summary will serve as both a written record of the appeal as well as an acknowledgment of the Plan’s receipt. These time limits may be extended by mutual written agreement.

Written appeals should include the member’s name, address, Plan ID number, daytime phone number, detailed description of the appeal (including relevant dates and provider names), any applicable documents that relate to the appeal, such as billing statements, and the specific result that has been requested. Written appeals can be faxed to 617-897-0805 or mailed to:

BMC HealthNet Plan
Member Appeals and Grievances
Two Copley Place, Suite 600
Boston, MA 02116

To submit an appeal in person, a member may go to any of the Plan’s office locations. Locations are listed in section 1 of this Provider Manual.

An appeal can be filed at any time within 180 days of the date of the original coverage denial. We encourage members and their Authorized Representatives to file any appeals as soon as possible.

Release of medical records: If the appeal requires the Plan to review medical records, a signed Authorization to Release Medical Records Form must be submitted to us. This form authorizes providers to release medical information to the Plan. It must be signed and dated by the member or member’s Authorized Representative. If an Authorization to Release Medical Records Form is not included with the appeal, the Appeals and Grievances Specialist will promptly send a blank form to the member or member’s Authorized Representative. This form must be signed and dated by the member or member's Authorized Representative. When signed by an Authorized Representative, appropriate proof of authorization to release medical information must be provided. If we do not receive this form within 30 calendar days of the date of receipt of the appeal, we may respond to the appeal without having reviewed relevant medical information. In addition, if we receive the form but a provider does not give the medical records to the Plan in a timely fashion, we will ask the member to agree to extend the time limit for a response.

All appeals will be processed by an Appeals and Grievances Specialist. Reviews will be performed by appropriate individuals who are knowledgeable about the issues relating to the appeal. Appeals regarding adverse determinations will be reviewed by health care professionals who have the appropriate clinical expertise in treating the medical condition, performing the procedure, or providing the treatment that is the subject of the Adverse Determination, who have not been involved in any prior review or determination of the particular appeal and who are not the subordinate of someone who was involved. During the appeal review process, the Plan will consult, if appropriate, with same or similar, board-certified specialty providers who typically treat the medical condition, perform the procedure, or deliver the treatment involved in the appeal. Decisions will be based on the terms of the member’s EOC, the opinions of the member’s treating providers, the opinions of our professional reviewers, applicable records provided by the member or providers, and any other relevant information available to us.

We will send a written response within 30 calendar days of receipt of the appeal. The 30 calendar day period begins as follows:

  • If the appeal requires the Plan to review a member’s medical records, the 30 calendar day period does not begin until the Plan receives a signed Authorization to Release Medical Information Form.
  • If the appeal does not require the Plan to review a member’s medical records, the 30 calendar day period begins: on the next working day following the end of the three working day period for processing inquiries through the internal inquiry process, if the inquiry was not addressed within that time period, or on the day the Plan was notified that the member was not satisfied with the response to the inquiry.

These time limits may be extended by mutual written agreement. Any extension will not exceed 30 calendar days from the date of the mutual agreement.

No appeal will be considered received by the Plan until it is actually received by the Plan at the appropriate address or telephone number listed above.

Written responses to Adverse Determinations will explain further avenues of appeal for the member, such as the member’s right to request an External Review from an Independent External Review Agency through the Massachusetts Department of Public Health/Office of Patient Protection.

If we don’t respond to the appeal within the timeframes described in this section, including any mutually agreed upon written extension, the appeal will be deemed decided in the member’s favor. Members are entitled to free access to and copies of any of their medical information related to their appeal that is in the Plan’s possession and under the Plan’s control.

10.7.5 Expedited Internal Appeals Process

An expedited appeal is a faster process for resolving an appeal. This faster process can be used when there has been a denial of coverage involving immediate or urgently-needed services. Examples of appeals that are eligible for the expedited appeals process are appeals involving substantial risk of serious and immediate harm; inpatient care; durable medical equipment; and terminal illness. Expedited appeals will not be used to review a benefit denial, which is a denial of coverage for a service, supply or drug that is specifically limited or excluded as outlined in the member’s Commonwealth Care or Commercial plans EOC.

An expedited appeal will be reviewed and resolved within 48 hours if it includes a signed certification by a physician that, in the physician’s opinion, the service is medically necessary; a denial of such service would create a substantial risk of serious harm; and the risk of serious harm is so immediate that the provision of such service should not await the outcome of the standard internal appeals process. The Appeals and Grievances Specialist will make reasonable attempts to notify the member, member's Authorized Representative, and treating provider orally of decisions involving expedited appeals. The Appeals and Grievances Specialist will also send written resolution to the member and/or member’s Authorized Representative within 48 hours of the request.

Inpatient care: The appeal will be expedited if the member is an inpatient in a hospital and the appeal concerns an Adverse Determination by the Plan that inpatient care is no longer medically necessary. This means we will review and resolve the expedited appeal before discharge. If our decision continues to deny coverage of continued inpatient care, we will send a written decision to the member upon discharge. The Appeals and Grievances Specialist will also make reasonable attempts to orally notify the member, member's Authorized Representative, and treating provider. If the member is inpatient, a health care professional or a hospital representative may be the member’s Authorized Representative without the member having to fill out an Authorized Representative Form.

Durable medical equipment (DME) needed to prevent serious harm: The appeal will be expedited if it includes a signed certification by a physician that, in the physician’s opinion: the DME is medically necessary; a denial of the DME would create a substantial risk of serious harm to the member (and describes the harm that will result to the member absent action within a 48 hour period); and the risk of serious harm is so immediate that the provision of the DME should not await the outcome of the standard internal appeals process. The certification must also specify a reasonable time period, not less than 24 hours, in which the Plan must provide a response. This means we will review and decide the expedited appeal and send a written decision within less than 48 hours of receipt of this certification. The Appeals and Grievances Specialist will also make reasonable attempts to orally notify the member, member's Authorized Representative, and treating provider.

Terminal illness: The appeal will be expedited if the member has a terminal illness (an illness likely to cause death within six months) and the member, member's Authorized Representative, or treating provider submits an appeal for coverage of services. This means we will provide a written resolution within five working days of receipt of the appeal. If our decision continues to deny coverage, the member may request a conference with us to reconsider the denial. We will schedule the conference within 10 days of receipt of the request. If the member’s physician, after consulting with our medical director, decides that the effectiveness of the proposed service would be materially reduced if not furnished at the earliest possible date, we will schedule the hearing within five working days. The member or member’s Authorized Representative may attend the conference. Following the conference, we will issue a written decision. The Appeals and Grievances Specialist will also make reasonable attempts to orally notify the member, member's Authorized Representative and treating provider.

We will decide all other expedited appeals within 48 hours of receipt. If we do not respond to the expedited appeal within these timeframes, including any mutually agreed upon written extension, the expedited appeal will be deemed in the member’s favor.

If an appeal concerns the termination of ongoing coverage or treatment, the disputed coverage remains in effect at our expense through the completion of the standard internal appeals process or expedited internal appeals process (regardless of the outcome of the process) if all of the following are true:

  • the appeal was filed on a timely basis,
  • the services were originally authorized by the Plan prior to the member or member's Authorized Representative filing an appeal (except for services sought due to a claim of substantial risk of serious and immediate harm),
  • the services were not terminated due to a specific time or episode related exclusion in the member’s EOC,
  • the member continues to be an enrolled member.

10.7.6 Reconsideration of a Final Adverse Determination

We may offer the member or member's Authorized Representative the opportunity for reconsideration of its final appeal decision on an Adverse Determination We may offer this when, for example, relevant medical information was received too late for us to review it within the 30 calendar days time limit for standard appeals, or was not received but is expected to become available within a reasonable time following our written decision on the member’s appeal. If the member or member's Authorized Representative requests reconsideration, the member or member's Authorized Representative must agree in writing to a new review time period not to be more than 30 calendar days from the agreement to reconsider the appeal.

10.7.7 Independent External Review Process

External Review Process for Your Appeal: The External Review process allows you to have a formal independent review of a final Adverse Determination made by us through our standard Internal Appeals Process or Expedited Internal Appeals Process. Only final Adverse Determinations are eligible for External Review with two exceptions: no final Adverse Determination is necessary if: (1) the Plan has failed to comply with timelines for the Internal Appeals Process, or (2) you (or your Authorized Representative) file a request for an Expedited External Review at the same time that you file a request for an Expedited Internal Appeal. Benefit Denials (i.e., denials based on coverage limitations and specific exclusions) are not eligible for external review.

External reviews are performed by an independent organization under contract with the Office of Patient Protection (“OPP”) of the Massachusetts Department of Public Health.

Members can request the external review or can ask for an Authorized Representative, including a healthcare provider or attorney, to act on the member’s behalf during the external review process. A member may be represented by anyone he or she chooses, including an attorney.

An Authorized Representative may be a family member, agent under a power of attorney, healthcare agent under a healthcare proxy, a healthcare provider, attorney or any other person appointed in writing to represent the member in a specific grievance or appeal.

How to request an external review: To request external review, the member or member's Authorized Representative must file a written request with the OPP within four months of receipt of the Plan’s written notice of the final appeal decision. A copy of the OPP’s external review forms and other information will be enclosed with our notice of its decision to deny a member’s appeal.

Expedited external review: The member, or member’s Authorized Representative, can request an expedited external review. To do so, a written certification must be submitted from a physician explaining that a delay in providing or continuing the health services that are the subject of the appeal would pose a serious and immediate threat to the member’s health. If the OPP finds that such a serious and immediate threat to the member’s health exists, it will qualify the request as eligible for an expedited external review.

You may file a request for an Expedited External Review either (1) after your receipt of the Plan’s final written decision on your Expedited Internal Appeal; or (2) at the same time as you file a request for an Expedited Internal Appeal.

Requirements for an external review:
The request must be submitted on the OPP’s application form called “Request for Independent External Review of a Health Insurance Grievance." We will send the form with the appeal denial response letter. Copies of this form may also be obtained by calling the Member Services department at 877-957-5300 (Commonwealth Care), 877-492-6967 (Commercial plans), by calling the OPP at 1-800-436-7757, or from the OPP’s website at mass.gov/Eeohhs2/docs/dph/patient_protection/external_review_form.pdf.

  • The form must include the member or member's Authorized Representative's signature consenting to the release of medical information.
  • A copy of our final appeal decision must accompany the form.
  • A $25.00 payment to the Office of Patient Protection must be enclosed for Commercial plan members. This fee is waived for Commonwealth Care members.

Coverage during the external review period: If the subject of the external review involves termination of ongoing services (outpatient or inpatient), the member or member’s Authorized Representative may apply to the External Review Agency to seek the continuation of coverage for the service(s) during the period the review is pending. Any request for continuation of coverage must be made to the review panel before the end of the second working day following the receipt of our final decision about the appeal. The review panel may order the continuation of coverage if it finds that substantial harm to the member’s health may result from termination of the coverage or for such other good cause as the review panel shall determine. The continuation of coverage will be at the Plan’s expense regardless of the final external review decision.

Access to information: The member or member’s Authorized Representative may have access to any medical information and records related to the external review that are in the Plan’s possession or under the Plan’s control.

Review process: The OPP will screen requests for external review to determine whether the member’s case is eligible for external review. If the OPP determines that the case is eligible for external review, it will be assigned to an External Review Agency that contracts with the OPP. OPP will notify the member, the member’s Authorized Representative (if applicable) and the Plan of the assignment. The External Review Agency will make a final decision and send it in writing to the member, member's Authorized Representative (if applicable), and to the Plan. For non-expedited external reviews, the decision will be sent within 60 calendar days of receipt of the case from the OPP. For Expedited External Reviews, the decision will be sent within four working days from receipt of the case from the OPP. The decision of the External Review Agency is binding on the Plan.

If the OPP determines that a request is not eligible for external review, the member or member's Authorized Representative will be notified within 10 working days of receipt of the request or, in the case of requests for expedited external review, within 72 hours of the receipt of the request.

How to reach the Office of Patient Protection (OPP):

Department of Public Health
Office of Patient Protection
99 Chauncy Street
Boston, MA 02111
Telephone: 1-800-436-7757
Fax: 1-617-624-5046
Website: mass.gov/dph/opp

10.8 Provider Reviews Related to Inquiries, Grievances, and Appeals

10.8.1 Monitoring Provider Performance

We monitor the performance of physicians, hospitals, and other participating healthcare providers related to member inquiries, grievances, and appeals by:

  • Conducting concurrent and retrospective chart reviews
  • Reviewing utilization patterns
  • Analyzing results of member satisfaction surveys
  • Compiling information from member inquiries, grievances, and appeals

10.8.2 Provider Quality Issues

We routinely send you feedback on a case-by-case basis as we identify quality issues. When we determine that a quality issue exists, the following procedure applies:

  • Our quality manager or a Plan medical director notifies you of the issue. You must respond orally or in writing to us within 30 calendar days of the notification. Your response is reflected in the final determination of the severity level. The severity rating ranges from “no quality of care issue was identified” to “a quality of care issue with confirmed significant adverse impact to the member.”
  • Upon receipt of your response, the medical director and/or the clinician reviewer, in conjunction with you, determines if a corrective action plan is required. These decisions are based on the severity level of the issue and your response.
  • The medical director and/or clinician reviewer works collaboratively with you to develop, implement and evaluate the corrective action plan. Modifications to the plan are made as appropriate. If you do not comply with the final plan, the medical director may take further action to resolve the concern.
  • Based on the severity of the quality of care issue, the medical director may require the Credentialing committee to conduct an off-cycle review of your practice.

We place documentation in your credentialing file, which we review when recredentialing you.

For further details about this process, please review section 9, Quality Management, or call your designated Provider Relations representative.

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