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What if MBHP or my MassHealth HMO denies my appeal?

Produced by Mental Health Legal Advisors Committee
Reviewed July 7, 2009

Appeal to the Division of Medical Assistance

If you have asked for a reconsideration and denied all the internal appeals of MBHP or your MassHealth HMO, you can then ask for a fair hearing before the Division of Medical Assistance (DMA).

You have the right to appeal any denial, reduction, or termination of service. The final denial decision you get from MBHP or the MassHealth HMO must include information about your right to appeal and a form to request a hearing with the Division of Medical Assistance. There are time limits, so it is important to read the notice carefully. Send the hearing request certified mail, return receipt requested (so that you can prove that you requested a hearing within the time limits). You also can fax the request.

How do I prepare for the hearing?

It is important to get medical evidence to support your claim. You can bring a doctor or other mental health clinician to the hearing to help your case. If she is unable to attend, she can write a letter that you can bring with you to the hearing. It is important that the letter clearly says why the mental health services you want are medically necessary and addresses the claims of MBHP or the HMO. It also is helpful to write out notes before the hearing and to bring copies of any documents or medical records that may help your case.

What will happen at the hearing?

You will be given an opportunity to present witnesses, ask questions and present your side of the story. The hearing is taped and all witnesses must take an oath.

At the end of the hearing you will have an opportunity to give a closing statement.

Advocacy tip:

The issue at the hearing is medical necessity. Be clear in what you say and limit your comments to why the services you want meet the medical necessity criteria in 140 C.M.R. §450.124:

  1. It is reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a handicap, or result in illness or infirmity; and
  2. There is no other medical service or site of service, comparable in effect, available, and suitable for the member requesting the service, that is more conservative or less costly to the Division.

Remember: The services you want must meet both standards in order to be medically necessary.

What will happen after the hearing?

You will receive a decision in the mail, usually within 90 days of the hearing. If you filed the request for a hearing within 10 days of the MBHP or HMO final decision, the services that you were getting won't be stopped until after a negative hearing decision if you asked for your services to be continued. (This applies only to services you were already receiving.)

An unfavorable decision can be appealed to the Superior Court. The Superior Court won't take new evidence on the facts of the case. The court will basically look to see if the process was fair and whether, given the evidence the hearing officer had, her decision was reasonable.

Call Mental Health Legal Advisors Committee, 617-338-2345 ext. 29 if you would like advice on how to file a request for a hearing before MassHealth's Board of Hearings.

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