Part 10 – Appeal and Grievance Program (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 92 review. The external review will be conducted by a review agency under contract with the Massachusetts Office of Patient Protection. How to Request an External Review To obtain an external review, you must submit your request on the form required by the Office of Patient Protection. On this form, you (or your authorized or legal representative) must sign a consent to release your medical information for external review. Attached to the form, you must send a copy of the letter of denial that you received from Blue Cross Blue Shield HMO Blue. In addition, you must send the fee required to pay for your portion of the cost of the review. The form, as well as the denial letter from Blue Cross Blue Shield HMO Blue, will tell you about your fee. Blue Cross Blue Shield HMO Blue will be charged the rest of the cost by the Commonwealth of Massachusetts. (Your portion of the cost may be waived by the Commonwealth of Massachusetts in the case of extreme financial hardship.) If you decide to request an external review, you must file your request within the four months after you receive the denial letter from Blue Cross Blue Shield HMO Blue. You (or your authorized or legal representative) also have the right to request an “expedited” external review. When requesting an expedited external review, you must include a written statement from a physician. This statement should explain that a delay in providing or continuing those health care services that have been denied for coverage would pose a serious and immediate threat to your health. Based on this information, the Office of Patient Protection will determine if you are eligible for an expedited external review. You (or your authorized or legal representative) also have the right to request an expedited external review at the same time that you file a request for an expedited internal formal review. If your request for a review is regarding termination of coverage for concurrent services that were previously approved by Blue Cross Blue Shield HMO Blue, you may request approval to have the disputed coverage continue until the external review process is completed. To do this, you must make your request before the end of the second working day after your receipt of the denial letter from Blue Cross Blue Shield HMO Blue. The request may be approved if it is determined that not continuing these services may pose substantial harm to your health. In the event that coverage is approved to continue, you will not be charged for those health care services, regardless of the outcome of your review. This continuation of coverage does not apply to services: that are limited by a day, dollar, or visit benefit limit and that exceed the benefit limit; that are non-covered services; or that were received prior to the time you requested the external review. To contact the Office of Patient Protection, you can call toll free at 1-800-436-7757. Or, you can fax a request to 1-617-624-5046. Or, you can go online and log on to the Office of Patient Protection’s Web site at www.mass.gov/hpc/opp. External Review Process The Office of Patient Protection will screen all requests for an external review. They will begin this screening within 48 hours of receiving a request for an expedited external review and within five business days for all other external review requests. The Office of Patient Protection will determine if your request for an external review: has been submitted as required by state regulation and described above; does not involve a service or benefit that is excluded by your health plan as explicitly stated in your health plan contract; and results from an adverse determination, except that no adverse determination is necessary when Blue Cross Blue Shield HMO Blue has failed to comply with the timelines for an internal appeal or grievance review or if you (or your authorized or legal representative) are requesting an expedited external review at the same time you are requesting an expedited internal formal review. When your request is eligible for an external review, an external review agency will be selected and your case will be referred to them. You (or your authorized or legal representative) will be notified of the name