What if the private insurer denies my appeal?

Ask for a reconsideration or file a further appeal

Private insurers and their contractors sometimes allow you to ask for a reconsideration or file a further level of appeal with the company. Information about this should be included with the decision denying your appeal.

If you can not ask for a reconsideration or file another internal appeal, you have two options to seek coverage:

1) Ask the Office of Patient Protection (OPP) to have a company review the insurer’s decision

It costs $25 and the decision is final. The fee may be waived in cases of financial hardship. Slightly more than half of the OPP reviews result in a change in or reversal of the insurer’s decision. You have 45 days from the date you receive a final adverse determination from your insurer to file for external review. For more information, contact the OPP at 1-800-436-7757 or download the review form from its website at //www.state.ma.us/dph/opp.

2) File a case in court

Another option is to file a case in court. Which court you file in depends upon your insurance coverage. It is advisable to get an attorney. This option costs more up front but gives you further levels of appeal if the first court decision denies coverage.

Advocacy Tip:

Whether you ask for an external review by the OPP or file in court, be prepared to submit evidence to support your request. Don’t just submit medical records. Get a letter from your doctor or therapist that clearly explains why the service you want is medically necessary.