OFFICE OF PATIENT PROTECTION

The mission of the Office of Patient Protection, an office within the Department of Public Health, is to protect the rights of patients who may have been unjustly denied coverage and provide information to carriers, insurers, HMOs and consumers, concerning new Managed Care legislation and regulations.

The OPP develops regulations and implements new statutory provisions governing managed care carriers' internal grievance procedures, detailing certain guarantees of continuity of care and specialty care referral and coverage, and establishing a process for obtaining an independent external review where coverage is denied based upon a medical necessity determination.

Effective January 1, 2001, Massachusetts consumers and other individuals who receive health coverage from a Massachusetts carrier, insurer or HMO are entitled to new protections covering internal grievances, medical necessity guidelines, continuity of care and external appeals. An insured individual who receives an adverse determination of an internal grievance has the right to an external review of a covered benefit within 45 days, and may obtain the necessary forms by calling the Department of Public Health Office of Patient Protection at 1-800-436-7757, or 617-284-8315 or by accessing their website at www.mass.gov/dph/opp to download copies of the forms.

Also available is a managed care Consumer Guide, member service telephone lines, contact information for HMOs licensed in Massachusetts, an extensive list of related links, and an FAQ section (in both English and Spanish) that simply explains terms and processes involved in filing grievances with health plans. This information can easily be obtained on their website or by calling the OPP directly.

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