I really need the service that my health plan or MassHealth denied. What can I do to change their decision?

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.