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Appealing Adverse Decisions of Carriers

Clinical Social Workers may appeal adverse decisions of carriers (i.e. insurance companies, managed care organizations and health maintenance organizations) under the regulations of the Division of Insurance (DOI) and the Office of Patient Protection (OPP, which recently moved from DPH to the Health Policy Commission). An appeal, or grievance, means “any oral or written complaint submitted to the carrier that has been initiated by an insured, or the insured’s authorized representative, concerning any aspect or action of the carrier relative to the insured, including, but not limited to, review of adverse determinations regarding scope of coverage, denial of services, rescission of coverage, quality of care and administrative operations…” To initiate this process the clinical social worker should contact the carrier via their “provider services” telephone number or email. This information is typically on the carrier’s “provider website,” for which you will need login access. The appeal/grievance process for the carriers should be similar, since they have to meet the minimum requirements of the DOI and OPP.

Medicare has its own appeals process, which can be found at on the website here.

If the provider and/or client/patient are unsuccessful in appealing an adverse decision within the carrier’s internal procedure, the OPP has a process for filing an “external grievance/appeal.” According to the OPP’s newly proposed amendments to 958 CMR 3.000: Health Insurance Consumer Protection, “Any insured or authorized representative of an insured who is aggrieved by a final adverse determination issued by a carrier or utilization review organization may request an external review by filing a request in writing with the OPP within four months of the insured’s receipt of written notice of the final adverse determination, except that no final adverse determination is required when the insured simultaneously requests an expedited internal review and expedited external review.”

The proposed amendments also provide for expedited reviews, stating that: “An insured or the insured’s authorized representative may request to have the request for review processed as an expedited external review. Each request for an expedited external review shall contain a certification, in writing, from a health care professional responsible for the treatment or proposed treatment that delay in the provision or continuation of health care services that are the subject of a final adverse determination, would pose a serious and immediate threat to the health of the insured. Upon receiving a properly executed certification that a serious and immediate threat to the insured exists, the OPP shall qualify such request as eligible for an expedited external review. The external review agency shall issue a decision within 72 hours of receiving the request for expedited external review.”

If you need more information about OPP guidelines or expedited reviews you can go to the OPP website, or call OPP at 1-800-436-7757.

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