Massachusetts External Review (OPP)

What is external review?

External reviewis a second level of appeal after the insurance company's internal grievance process. In Massachusetts, the Office of Patient Protection (OPP) administers external review and assigns your case to an accredited independent review agency with clinical panelists (M.G.L. c. 176O, § 14).

For eligible medical-necessity disputes, the panel decision is binding on you and the carrier. OPP can help determine eligibility and walk you through filing.

General overview: Appeals roadmap. Complete Massachusetts internal appeals first unless an exception applies.

Who can use Massachusetts review?

External review through OPP generally applies when:

• You have a fully insured Massachusetts health plan subject to c. 176O
• The dispute involves medical necessity or whether a treatment is a covered benefit
• You exhausted internal grievance (or qualify for an exception under § 14(a))

Usually does not apply to:

• Self-funded ERISA employer plans
• MassHealth / Medicaid (MCO appeal and Board of Hearings fair hearing)
• Medicare
• Pure billing, coding, or eligibility disputes without a medical-necessity component

Deadlines & exhaustion

Four-month filing window

OPP requires requests within 4 months of your final adverse determination letter after internal appeal (Mass.gov — request external review).

Exhaust internal grievance first

Normally complete the carrier's formal grievance process under § 13, unless (§ 14(a)):

• You request expedited external review
• The carrier failed to meet § 13 time limits (grievance deemed resolved in your favor)

You may request expedited internal and external review at the same time (§ 13(d)).

How to file

1. Complete internal grievance and keep the final adverse determination letter.
2. Gather medical records, denial letters, and grievance correspondence.
3. Submit an external review request to OPP:
   • Mass.gov — external review request
   • masshpc.gov/opp
4. OPP determines eligibility and refers eligible cases to a review agency. Do not email PHI unless using secure methods OPP approves.

Questions: OPP 800-436-7757 (TTY via MassRelay 800-720-3480).

How long it takes

• Standard: review panel sends final written disposition within 45 days of receiving the request (§ 14(a))
• Expedited: within 72 hours of receipt when expedited review applies (§ 14(b))

OPP materials note the 45-day period generally starts when the review agency receives the case from OPP.

Is the decision binding?

Yes—the review panel decision is binding on the insured and the carrier(§ 14(c)). The Superior Court may enforce the decision. A carrier's failure to comply promptly may violate chapter 93A (unfair practices).

Grievance procedures are in addition to other contract or legal remedies—failure to use them does not block other remedies ( § 14(e)). During review, certain debt collection and credit reporting restrictions apply (§ 14(f)).

Medicaid & Medicare

MassHealth

MassHealth uses MCO appeals and Board of Hearings fair hearings—not OPP § 14 review (How to appeal a MassHealth decision).

Medicare

Use Medicare appeal levels—see Medicare appeals.