What is an internal appeal?
An internal appeal—called a grievance under Massachusetts law—asks the insurance company to reconsider its adverse determination about coverage, payment, or prior authorization.
This is different from external review, where the Office of Patient Protection (OPP) assigns an independent review panel after internal grievance is complete (with exceptions).
General walkthrough: Appeals roadmap. Massachusetts specifics below.
Massachusetts appeal timelines
M.G.L. c. 176O, § 13 requires a formal internal grievance process (read statute):
- Written acknowledgement of a grievance within 15 days
- Written resolution by certified or registered mail (or express carrier with proof of delivery) within 30 days of receipt
- Grievances accepted by phone, in person, mail, and electronic means
- Right to appoint an authorized representative; OPP consumer assistance number on notices
- Federal Affordable Care Act appeal standards also apply to many plans
Deemed resolved in your favor
A grievance not properly acted on within required time limits is deemed resolved in favor of the insured and is immediately eligible for external review if the carrier disputes compliance (§ 13(c)).
Expedited grievances (§ 13(b))
- Resolution before hospital discharge for inpatient grievances
- Possible automatic reversal of certain denials within 48 hours when a physician certifies immediate serious harm
- 5 days for terminal illness grievances
- 72 hours for urgently needed services
Exhaustion before OPP review
Under § 14(a), you generally must exhaust internal grievance before OPP external review, unless you seek expedited review or the carrier missed § 13 deadlines.
How to file
- Read the adverse determination letter for deadlines and grievance instructions (must describe internal and external review rights).
- Submit the grievance to the carrier using its process; keep proof of delivery.
- Request expedited review if hospitalized or facing urgent harm.
- Call OPP at 800-436-7757 for help understanding rights or next steps.
Carrier links: Massachusetts prior auth & internal appeals links.
Evidence that helps
- Treating provider letter on medical necessity
- Clinical records and the carrier's medical review criteria
- Peer-reviewed literature for experimental/investigational disputes
MassHealth appeals
MassHealth members in managed care must usually exhaust the MCO internal appeal before a state fair hearing (Mass.gov — appeal MassHealth). Fair hearing requests are often due within 60 days of MassHealth agency notice or 120 days after an MCO appeal resolution (130 CMR 610.015)—follow your notice.
MassHealth Customer Service: 800-841-2900 (TTY 711).
After internal appeal
If the carrier upholds denial, keep the final adverse determination letter with OPP external review instructions.
Next step: Massachusetts external review (OPP).