Whom to contact:

Maine Bureau of Insurance, Consumer Health Care Division

Who can appeal:

You, your provider (with consent), or your authorized representative

What you can appeal:

Denials of coverage for services the health plan determines are not medically necessary, are experimental or investigational, or are based on pre-existing condition exclusions.

When you can appeal:

You must file within 12 months from receipt of the final adverse health care treatment decision. Although you must usually exhaust all levels of the health plan’s internal process, this is not required if:

• The internal grievance is not resolved in the required time period,
• You and your health plan agree to bypass the internal procedure,
• Your life or health is in serious jeopardy, or
• You have died.

What to send:

A written request to the Maine Bureau of Insurance, Consumer Health Care Division

What you must pay:

No charge

What will happen:

• The Bureau of Insurance sends your request to a contracted independent review organization.
• You have the right to request a hearing (telephone conference).
• The health plan has to send all pertinent records to you and the review organization.
• You may submit additional information to the review organization. (who will send copies of that information to your health plan).
• The review organization will make a decision and notify you, your health plan, and the Bureau of Insurance.

When you will get a decision:

Within 30 days of the date the case is received by the external review organization

In urgent situations:

If delay will seriously jeopardize your life, health or ability to regain maximum function, the decision must be made within 72 hours of the request for review.