Independent medical reviews in Massachusetts

If you or an authorized representative asked for an appeal and got a resolution letter saying our decision stayed the same, and you do not agree, you have the right to ask for an external appeal. You or your authorized representative can also ask for an external appeal if you asked for an appeal but did not get a resolution letter, and more than 30 days have passed since you filed your appeal.

You can ask for a State Fair Hearing. You may also be able to ask for an Independent Review Organization (IRO) appeal.

External appeals are at no cost.

You may be able to have your services continue while your case is reviewed. To ask for continued services, call Molina One Care Member Services at  (833) 755-1735 (TTY: 711), or Senior Whole Health SCO Member Services at (888) 794-7268 (TTY: 711), Hours are October 1 to March 31, 8 a.m. to 8 p.m. local time, 7 days a week. From April 1 to September 30, Monday to Friday, 8 a.m. to 8 p.m. local time.

State Fair Hearing

A State Fair Hearing lets a judge who is not part of Molina Healthcare review your case.

You must ask for a State Fair Hearing within 120 days from the date on the letter telling you the appeal decision. The judge’s decision is final, and we must follow it.

If waiting for a State Fair Hearing could harm your life, health, or ability to function, you, your provider, or your authorized representative can ask the Executive Office of Health and Human Services– Office of MassHealth (Medicaid) Board of Hearings (BOH) for a fast (expedited) hearing. BOH must make a decision no later than three business days after getting your complete case file from Molina Healthcare.

You can read more in your Member Handbook.

How can you ask for a State Fair Hearing?

You can file a State Fair Hearing in different ways

• Online: Visit Mass.gov.
• Fax: Fill out the form that came with your appeal resolution letter and fax it to (617) 887-8797.
• Phone: Call (800) 841-2900 (TTY: 711).
• Mail: Fill out the form that came with your appeal resolution letter and send it to:

The Board of Hearings

Office of Medicaid

100 Hancock Street, 6th floor

Quincy, MA 02171

If you need help asking for a State Hearing, we can help. We offer no-cost language services. Call Molina One Care Member Services at  (833) 755-1735 (TTY: 711), or Senior Whole Health SCO Member Services at  (888) 794-7268 (TTY: 711). Hours for Member Services are October 1 – March 31, 8 a.m. to 8 p.m. local time, 7 days a week. From April 1 – September 30, Monday – Friday, 8 a.m. to 8 p.m. local time.

Independent Review Organization (IRO) appeal

An IRO lets an independent doctor who is not part of Molina Healthcare review your case. Their decision is final, and we must follow it.

You must ask for an IRO within six months from the date on the letter telling you the appeal decision.

You can read more in your Member Handbook.

How can you ask for an Independent Review Organization (IRO) appeal?

You can call the Office of Patient Protection to ask for an IRO.

• Toll-free: (800)-436-7757.
• TTY: (800) 720-3480.

You can also get the IMR/Complaint Form and learn more at: Mass.gov.

Important Timeframes

You must ask for an IRO within six months from the date on the letter telling you the appeal decision.

You have 120 days to ask for a State Fair Hearing.

If you want both a State Hearing and an IRO, ask as soon as you can.

Important:
If you first ask for a State Fair Hearing and the hearing already happened, you cannot ask for an IRO. In that situation, the State Fair Hearing decision is final.

Cost

You do not have to pay for a State Fair Hearing or an IRO.

You can read more about these rights in your Member Handbook.