Requests Ineligible for External Review – Notification

(1) Notification of the rejection of a request for external review for failure to meet the requirements of 958 CMR 3.400 shall be issued by the Office of Patient Protection to the insured, the insured's authorized representative and the carrier within 72 hours of a receipt of a request for an expedited review and within ten business days of receipt of all other requests. The notification shall set forth the specific reason why the request has been determined ineligible for an external review and any submitted fee shall be returned. (2) The Office of Patient Protection shall determine that a request for external review is ineligible for review based on the following: (a) Insured or insured's authorized representative filed the request for external review after the time limit provided at 958 CMR 3.400; (b) Insured seeks external review of a decision by a self-funded plan not eligible for review under M.G.L. c. 176O; (c) Insured seeks external review of a decision by a health benefit plan licensed in a state other than Massachusetts, which is not eligible for review under M.G.L. c. 176O; (d) Insured seeks external review of a decision by a plan issued by Medicaid, Medicare, or other health benefit plan not subject to M.G.L. c. 176O; (e) Insured's treatment was found to be medically necessary by the carrier, and the insured is attempting to seek external review of an issue related to the amount of copayment, deductible, coinsurance or other out-of-pocket expense; or (f) Insured seeks external review of a decision by a carrier which was not a final adverse determination, except that an adverse determination will be sufficient where the insured seeks an expedited external review and has simultaneously filed a request for expedited internal review.