My Ombudsman can work with you one-on-one to discuss your rights and choices if you disagree with a coverage decision your health plan made. In general, you have the right to file an appeal or a grievance.

An appeal is an official way of asking your health plan (or in some cases MassHealth) to change a decision. When you file an appeal, you get to tell your health plan or MassHealth in your own words why you disagree with their decision. The provider who requested the service or care that was denied can also help with this process.

A grievance is a formal way of telling your health plan that you are not happy with their actions. This type of complaint is a way to get your concerns “on the record,” but it may not result in a different outcome or change their decision. The plan is still required to respond (usually in writing) to your concerns.

My Ombudsman can help you understand why your service was denied, explore your choices, and help you navigate the process of an appeal or grievance. We can’t represent you in an appeal, which means we can’t serve as your advocate and tell MassHealth or your health plan to make a decision in your favor.

There are many reasons why a member can receive a denial letter. For example: Maybe MassHealth or your health plan needs more information. Or maybe the service requested is not something MassHealth or your health plan usually covers. Maybe the health plan and doctor disagree about whether the service is medically necessary. Or, the reason may be something else altogether.

If you receive a letter like this, we suggest reading it carefully and holding onto it. The letter should describe the reason for your denial and the next steps you can take, like filing an appeal. Contact your MassHealth or your health plan if you need help understanding what the letter says. If you need further assistance, you are welcome to contact My Ombudsman. We can discuss the letter together to see if we can help you understand the health plan’s decision. We can also discuss your options, including your right to ask for an appeal.