How to appeal a health insurance denial in Massachusetts
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. Massachusetts lets you ask an independent reviewer to decide, through Massachusetts Health Policy Commission, Office of Patient Protection. The deadline to ask: within 4 months of receiving your final adverse determination letter.
Does this apply to you? State external review covers plans regulated by Massachusetts: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in Massachusetts
Within 4 months of receiving your final adverse determination letter
The external review agency must decide within 72 hours. You may request expedited external review at the same time as an expedited internal appeal; to keep ongoing coverage during the review, ask within 2 business days of the final denial.
$25 per review ($75 max per year), waived for financial hardship; refunded if the decision is completely in your favor
State-regulated plans (insurance bought in Massachusetts or through an employer that buys insurance). Self-funded employer plans use the federal process.
File with the Office of Patient Protection (secure online form, USPS mail only, fax 617-624-5046, or in person), not the Division of Insurance or the insurer; OPP will not accept requests by email. Only medical-necessity denials qualify (services explicitly excluded by the plan do not), and the plan must be fully insured and licensed in Massachusetts. No Surprises Act billing disputes go to the federal contractor Maximus (OPP will forward them).
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in Massachusetts?
Within 4 months of receiving your final adverse determination letter
Can I get a fast external review in Massachusetts?
The external review agency must decide within 72 hours. You may request expedited external review at the same time as an expedited internal appeal; to keep ongoing coverage during the review, ask within 2 business days of the final denial.
Does external review cost anything in Massachusetts?
$25 per review ($75 max per year), waived for financial hardship; refunded if the decision is completely in your favor
Do Massachusetts’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- HPC Office of Patient Protection: Request an External Review of a Health Insurance Decision
You have 4 months from receipt of a final adverse determination letter from your health insurance company to request an external review.
- 958 CMR 3.400 External Review
within four months of the insured's receipt of written notice of the final adverse determination
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.