Appeal

Where a breast cancer patient is denied coverage by a health care or insurance provider specified in 105 CMR 240.003, and claims to be eligible for bone marrow transplantation under 105 CMR 240.000, an independent and impartial appeal process shall be made available to the patient. 240.007: continued (A) The patient may be required by the health care or insurance provider to exhaust available internal appeals procedures; provided, however, that if the matter is not resolved internally to the patient's satisfaction within 30 days of initiating the appeal, the health care provider or insurer shall refer the matter for final resolution to an impartial and independent review board meeting the requirements of 105 CMR 240.007. (B) The Department shall establish a list of review boards to which the health provider or insurer may refer an appeal required under 105 CMR 240.007. Review boards may be included in the list if the Department has reason to believe that they will conduct an impartial, independent, fair and timely review of appeals. (C) If the health provider or insurer utilizes a review board from the Department's list for its own internal appeals process, such review shall satisfy the requirement for an impartial and independent appeal under 105 CMR 240.007. (D) In the event that the Department is not satisfied with the impartiality, independence, timeliness or fairness of appeals boards seeking to be or already listed, the Department may establish its own appeals board, to be comprised of members of the medical, insurance, and consumer communities.