In Maine, the entity that coordinates the independent external review of health insurance denials is the Maine Bureau of Insurance.
The Bureau contracts with various independent review organizations (IROs), which are impartial entities not associated with your insurance company, to conduct the review of your case.
How to Request an External Review
To initiate the external review process, you must typically exhaust your insurance company’s internal appeals process first (usually two levels of appeal for a group plan, or one level for an individual plan), unless it is an expedited case where your life or health is in serious jeopardy.
- Contact the Maine Bureau of Insurance: You or your representative should contact the Bureau to request an external review application and determine your eligibility.
- Website: You can find resources and the application form on the Maine Bureau of Insurance website.
- Submit Required Forms: The Bureau will send a packet with forms, including an authorization and contact sheet. You must complete and return these forms, along with a copy of your final denial letter from the insurer.
- IRO Assignment: The Bureau will assign your case to an IRO. The IRO will appoint a health care professional with expertise in the relevant medical issue to review your case.
- Decision: The IRO’s decision is binding on the insurance company. The process usually takes around 30 days to complete, or 72 hours for expedited reviews.
Was your Denial for bills for covered Emergency Services?
If the answer is yes, you can request an Independent Dispute Resolution (IDR).
The Maine Bureau of Insurance has contracted with IMPROVE Health to resolve certain disputes involving bills for covered emergency services rendered by out-of-network medical service providers. Independent dispute resolutions apply to out-of-network bills for emergency medical services rendered on or after October 1, 2020.
Note: The IDR Process is only for emergency services claim disputes involving out-of-network providers, enrollees in a self-insured plan that has opted into Maine’s IDR process and certain uninsured consumers.