Massachusetts external review for health insurance denials
After the final internal appeal in Massachusetts, an independent organization can re-decide your claim. Massachusetts Office of Patient Protection (Health Policy Commission) oversees the process.
- Regulator
- Massachusetts Office of Patient Protection (Health Policy Commission)
- Program type
- State-administered external review
- Filing window
- Federal default: 4 months after the final internal denial (45 CFR 147.136(d)). Confirm the Massachusetts deadline at the official page below.
- Department site
- https://www.mass.gov/orgs/health-policy-commission
What external review covers
External review applies to adverse benefit determinations involving medical judgment — denials based on medical necessity, appropriateness, level of care, effectiveness of a covered benefit, or whether a treatment is experimental or investigational. It also covers rescissions of coverage. It does not apply when the denial is based on an explicit benefit exclusion in your plan document.
For an expedited request (when the standard timeframe would seriously jeopardize life, health, or ability to regain maximum function), the reviewer must decide as soon as possible and no later than 72 hours.
How to file in Massachusetts
- Exhaust the insurer's internal appeals process. Keep the final adverse benefit determination letter — you'll need it.
- Open the Massachusetts external review page at https://www.mass.gov/external-review-of-an-insurance-claim and use the request form posted there.
- Submit the final denial letter, your provider's medical necessity letter, supporting medical records, and any relevant guideline or peer-reviewed citations. The state-assigned IRO will review the full record.
- The standard decision is typically issued within 45 days. The insurer is bound by the decision if the IRO reverses the denial.
Massachusetts notes
Massachusetts external review is run by the Office of Patient Protection under M.G.L. c. 176O, § 14.
Upload the final denial letter. The free analysis builds the IRO submission packet: medical necessity letter, evidence list, and policy citations.