You must file your request for an external review with the Massachusetts Office of Patient Protection (“Office”) within four months of the date on your insurer’s most recent decision.

Information. You can find a copy of the external review request form here.^[14] You should include the following information:

• Patient’s name, address, telephone number, and date of birth;
• Policyholder’s name;
• Patient’s insurance identification number;
• Name of health insurance company;
• Name of the person at the insurance company involved with the appeal;
• Description of the problem;
• Name, address, and telephone number of the health care provider who ordered the service which was denied; and
• Information regarding your health history, if you want that information to be considered by the external review agency.^[15]

Supporting documents. You should also include the following supporting documents with your application:

• A copy of all determination letters from your health insurer;
• A signed medical records release form (included with request packet);
• A copy of your insurance card; and
• Any medical records, health care provider statements, and other information for the external review agency to consider.

If you are requesting an expedited external review, you should also include the following documents with your application:

• The “Request for Expedited Review” section on page 9 of the external review request packet;^[16] and
• The “Certification for Expedited External Review” form included on pages 10 – 11 of the external review request packet.^[17]

Filing fee. You must include a $25 filing fee with your application. The fee is payable by check or money order.^[18] If the external review is resolved in your favor, the Office will refund your payment. If the fee would create an extreme financial hardship for you, you can request a waiver of the fee by completing a fee waiver form. The form is on page 8 of the external review request form, which can be found here. The form contains a chart, which explains what qualifies as “extreme financial hardship.”

How to submit a standard external review request. If you are requesting a standard external review, you should submit your request and supporting documents by fax to (617) 624-5046 or by mail to the following address:^[19]

Office of Patient Protection
Health Policy Commission
50 Milk Street, 8^th Floor
Boston, MA 02109

How to submit an expedited external review request. If you are requesting an expedited external review, you should fax your request and supporting documents to the Massachusetts Office of Patient Protection at (617) 624-5046.^[20]