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Appeals and Complaints

Appeals

If you disagree with a decision made by your child’s health plan, you or your child’s primary care provider (PCP) may appeal to the plan. For example, you may request that a decision be reviewed if:

  • The plan refuses to pay for treatment that you and your child’s PCP believe your child needs
  • The plan tells you that it will stop paying for treatment

Check the benefits handbook or contact a member services representative at the plan for more information about how to appeal a decision. Ask for a copy of your plan’s policy on prior approval and appeals. The representative will work with you to help you find the best way to address the problem.

Federal law requires that a health plan allow you to appeal a decision up to 180 days from the service date. It is best to file an appeal as soon as you can. Remember to keep a written record of everything you do and everyone you speak to. Also, keep copies of any letters you send or forms you fill out.

If your appeal is denied by your health plan, you may have additional rights through the Office of Patient Protection (OPP) at the Massachusetts Department of Public Health. Information about additional rights should be provided in the final denial letter you receive from your health plan. Please note that in some plans, decisions are not eligible for outside review by the OPP.

Complaints

At times you may not be satisfied with the care your child has received and may want to notify the health plan with your concerns. Contact a member services representative for information on filing a complaint or grievance. If you have a case manager, you may want to share the information with that person as well.

You may also contact the Office of Patient Protection (OPP) at the Massachusetts Department of Public Health for general information about managed care, referrals, grievances, and appeals. The OPP can explain your rights, and may be able to help resolve your complaint or grievance. Contact the OPP at 800-436-7757 or 617-624-6001 (TTY).

This information is provided in part by the Division of Perinatal, Early Childhood, and Special Health Needs within the Massachusetts Department of Public Health and mass.gov.

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