Health insurance or Medicaid said no in Massachusetts? Deadlines and free help

In Massachusetts, state-regulated health plans are overseen by Massachusetts Division of Insurance (DOI), Consumer Services Unit and Health Policy Commission, Office of Patient Protection (OPP).

Massachusetts runs its own independent review of denials: External Review (Office of Patient Protection). You generally have 4 months to ask for it.

External review means a doctor or reviewer outside your plan decides again. Internal appeal means your plan looks at its own decision again.

Pick your plan type

Which kind of coverage was denied? The plan type decides which rules and deadlines apply.

Insurance I bought or got through work

Your state insurance rules may apply. First appeal to your plan, then ask for an outside review.

My employer pays claims itself (self-funded)

Federal rules apply, and most state insurance laws do not. Free help comes from the U.S. Department of Labor.

Medicaid / MassHealth

You ask the state for a fair hearing. In a Medicaid health plan, you usually appeal to the plan first.

Marketplace (Massachusetts Health Connector) decision

A decision about whether you can buy a plan or get financial help is appealed to the Marketplace.

How long do I have?Urgent care: faster decisionWrite my appealFree help

Checked against official sources: October 30, 2026.

Appeal deadlines are strict. If you are near a deadline or your care is urgent, call free help today.

How long do I have in Massachusetts?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
4 months
Hearing deadline
60 days
Appeal to the plan first
60 days (federal rule)
Then a state hearing
120 days
Appeal deadline – Massachusetts Health Connector
60 days

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How long do I have? Deadline calculator

How do I know which plan type I have?

How to tell which agency regulates your plan

If your plan comes from your employer, the state external review only covers fully insured plans licensed in Massachusetts; self-funded (self-insured) plans are regulated by the federal government. Your employer's benefits office can tell you which kind you have. Medical necessity denials go to the Office of Patient Protection; other complaints about an insurer go to the Division of Insurance.

Step 1: Appeal to your plan in Massachusetts

What it is called: Internal grievance (internal appeal)

Your insurer must accept your appeal by phone, mail, in person, fax or electronically, and must confirm it in writing within 15 days. It must send a written decision within 30 days. For immediate and urgently needed services, it must decide within 72 hours; for a person with a terminal illness, within 5 days; for a hospital inpatient, before discharge. If your doctor certifies that a denied service or equipment is medically necessary and that waiting would create a substantial risk of serious harm, the denial is automatically reversed within 48 hours while the appeal goes on. If the insurer misses its deadline, the grievance is decided in your favor. Ongoing coverage or treatment that is being ended stays in place until the internal grievance process is finished.

Law: Mass. Gen. Laws c. 176O, s. 13(a)-(c), s. 14(b)

All the details →

Step 2: Outside review in Massachusetts

External Review (Office of Patient Protection)

Deadline to ask: 4 months.

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Urgent care in Massachusetts: faster decisions

Outside review

For urgently needed care you can ask for an expedited review. The review agency must decide within 72 hours. OPP can help you find out if your case qualifies. You can also ask the reviewers to keep paying for care that is being stopped while the review goes on, if stopping it could cause substantial harm to your health; ask within 2 business days of receiving the final adverse determination, together with your expedited review request.

Law: Mass. Gen. Laws c. 176O, s. 14; Mass. Gen. Laws c. 958 CMR 3.000

Standard: 45 days; Urgent: 72 hours

Medicaid

In limited cases an expedited hearing may be provided; the Board of Hearings schedules it automatically when needed.

Law: 130 CMR 610.015

Marketplace

If you have serious health needs and your ability to get care depends on the appeal, call the Health Connector Appeals Unit at 617-933-3096 (TTY 711) to ask for a faster decision.

Complaints about your plan in Massachusetts

For other problems with an insurer, you can file a complaint with the Division of Insurance Consumer Services Unit online, by email to CSSComplaints@mass.gov, by mail to Division of Insurance, Consumer Services Unit, 1 Federal Street, Suite 700, Boston, MA 02110, or by fax to 617-753-6830. The DOI does not make medical necessity decisions; those go to the Office of Patient Protection.

www.mass.gov

Medicaid (MassHealth) denials in Massachusetts

Who holds the hearing: Office of Medicaid, Board of Hearings (BOH).

Hearing deadline: 60 days

All the details →

Marketplace decisions in Massachusetts

Marketplace

Massachusetts Health Connector · 1-877-623-6765

Appeal deadline

60 days

The date you received the Health Connector notice you want to appeal

How to appeal

Fill out the Hearing Request Form that came with your notice and mail it to Massachusetts Health Connector Appeals Unit, P.O. Box 960189, Boston, MA 02196, or fax it to 1-617-933-3099, or use the online Hearing Request Form. For appeals by phone, call 1-877-MA-ENROLL (1-877-623-6765), TTY 711. If the Health Connector failed to act, you have 120 days from the date you believe it should have acted. Hearings are held by phone unless an in-person hearing is approved.

Form

Health Connector online Hearing Request Form

Faster appeal

If you have serious health needs and your ability to get care depends on the appeal, call the Health Connector Appeals Unit at 617-933-3096 (TTY 711) to ask for a faster decision.

Coverage while you appeal

You may be able to keep your Health Connector plan while your appeal is decided; the Health Connector tells you after it gets your form. If you keep benefits and lose, you may have to pay them back.

Other rights in Massachusetts

If the insurer misses its deadline

If your insurer does not decide your internal grievance within the time limits, the grievance is treated as decided in your favor, and the claim can go straight to external review, where it is decided for you unless the insurer proves it met the deadline.

Law: Mass. Gen. Laws c. 176O, s. 13(c)

No credit reporting or debt collection during review

While an internal or external review is pending, and for 30 days after it is resolved, a provider may not report the unpaid charges to a credit reporting agency or start debt collection on them.

Law: Mass. Gen. Laws c. 176O, s. 14(f)

Automatic reversal for urgent care

During an expedited grievance, a denial of services or durable medical equipment is automatically reversed within 48 hours, until the appeal is decided, if your treating doctor certifies that the care is medically necessary and that denying it would create a substantial and immediate risk of serious harm.

Law: Mass. Gen. Laws c. 176O, s. 13(b)(ii)

How long do I have? Deadline calculator

Pick your plan type and enter the dates on your notice. We count from the rules in Massachusetts and the federal rules.

Worked out in your browser. Nothing you enter here is saved or sent.

If you are not sure when it arrived, use the date printed on the notice. That date is never later than the day it arrived.

Choose what was decided and enter the date on your notice

We add the number of days or months from the law to your date. Nothing is saved.

Write my appeal: free letters

Free help in Massachusetts

Good to know in Massachusetts

  • In Massachusetts the state external review is run by the Office of Patient Protection at the Health Policy Commission, not by the Division of Insurance.

    Law: Mass. Gen. Laws c. 176O, s. 14

  • Massachusetts charges a $25 external review fee, capped at $75 per plan year, waivable for hardship and refunded if you win in full.

    Law: Mass. Gen. Laws c. 176O, s. 14(a)

  • MassHealth gives 60 days from receipt of the notice to ask for a fair hearing, and 120 days after a managed care plan's final appeal decision.

    Law: 130 CMR 610.015(B)

Questions about appeals in Massachusetts

How long do I have to appeal a health insurance denial in Massachusetts?

You have 180 days from the date of the denial notice or Explanation of Benefits to ask your insurer for an internal appeal. You have at least 180 days (about 6 months) from when you receive the denial notice to file an internal appeal.

How do I get an outside (external) review in Massachusetts?

External Review (Office of Patient Protection). Fill out the OPP Health Insurance External Review Form (online, or on paper in English or Spanish) and send it with a copy of the final adverse determination letter and any medical records or letters from your provider. Send online, by U.S. Postal Service mail with no signature required to Health Policy Commission, Office of Patient Protection, 50 Milk Street, 8th Floor, Boston, MA 02109, by fax to 617-624-5046, or in person.

Is outside review free in Massachusetts?

You pay a $25 fee for each external review, but never more than $75 in one plan year. OPP can waive the fee for financial hardship.

How long do I have to ask for a Medicaid fair hearing in Massachusetts?

60 days. The date you received the written MassHealth notice.

Can I keep my Medicaid benefits while I appeal in Massachusetts?

You keep your benefits during the appeal if the Board of Hearings receives your request before your benefits stop or within 10 calendar days of the date you received the notice, whichever is later. Check the box on the form.

How do I appeal a Marketplace decision in Massachusetts?

Fill out the Hearing Request Form that came with your notice and mail it to Massachusetts Health Connector Appeals Unit, P.O. Box 960189, Boston, MA 02196, or fax it to 1-617-933-3099, or use the online Hearing Request Form. For appeals by phone, call 1-877-MA-ENROLL (1-877-623-6765), TTY 711. If the Health Connector failed to act, you have 120 days from the date you believe it should have acted.

Not about a denied claim?

Nearby states

Sources

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