Right to an Internal Appeal

(1) Risk-bearing Provider Organizations or Accountable Care Organizations shall maintain an internal appeal process that provides for adequate consideration and timely resolution of Patient concerns about denials, restrictions, or limitations of care. (2) The internal appeals processes shall apply to decisions of the RBPO, ACO or the ACO or RBPO Participants relating to denials, restrictions or limitations of care regarding: (a) Referrals to Providers not affiliated with the RBPO or ACO; (b) The type or intensity of treatment or services; (c) Timely access to treatment or services; and (d) Other concerns related to the Patient’s care provided by an RBPO or ACO or RBPO or ACO Participant that are related to Provider participation in an Alternative Payment Contract. (3) The RBPO or ACO shall not: (a) Require a Patient to submit such an appeal in writing. (b) Prevent a Patient from seeking medical opinions outside of the RBPO or ACO. (c) Terminate any medical or behavioral health services being provided to the Patient during the internal appeal or external review, including medical or behavioral health services which began prior to the Patient appeal and are the subject of the appeals process in 958 CMR 11.00; or (d) Limit or restrict access to appeals process in 958 CMR 11.00.