Appeal Process for Enrollees in an Integrated Care Organization

The Duals Demonstration Program uses a coordinated appeals process that provides enrollees with access to both the MassHealth and Medicare appeals processes. If the ICO internal appeals process denies a member’s requested covered benefits in whole or in part, the member may appeal to either IRE, BOH, or both, as described in 130CMR 610.018(A) through (C). (A) If the member’s appeal is denied in whole or in part, the ICO must automatically forward an external appeal about Medicare services to the IRE. The member may simultaneously appeal the ICO decision to the BOH. (B) Services that are not covered by Medicare fee-for-service may only be appealed to the BOH. The ICO must notify the member if the service is not covered by Medicare and that the member has the right to appeal to the BOH. (C) If the BOH or the IRE decides in the member’s favor, the ICO must provide or arrange for the service in dispute as expeditiously as the member’s health condition requires but no later than 72 hours from the date the ICO receives the notice of the BOH or the IRE decision. (130 CMR 610.019 through 610.025 Reserved)