How to appeal a health insurance denial in Maine
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. Maine lets you ask an independent reviewer to decide, through Maine Bureau of Insurance. The deadline to ask: within 12 months of receiving a final decision on your appeal.
Does this apply to you? State external review covers plans regulated by Maine: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in Maine
Within 12 months of receiving a final decision on your appeal
Decision within 72 hours of a completed request (without a hearing) when the standard timeline would seriously jeopardize life, health or ability to regain maximum function. You may apply for expedited external review at the same time as an expedited internal appeal; not available once services have been rendered.
Free (no filing fee; the insurer pays the cost of the review)
State-regulated plans (insurance bought in Maine or through an employer that buys insurance). Self-funded employer plans use the federal process.
File with the Bureau of Insurance (online application or mailed PDF form), not the insurer. Group plans must finish all internal appeal levels (usually two) and individual plans one; you may ask for a telephone hearing with the review organization. 800-300-5000 is toll-free in Maine only; otherwise call 207-624-8475 (external review nurse consultant: 207-624-8459). Some trusts and self-funded plans still qualify, so ask the Bureau.
Who to contact
- Maine Bureau of Insurance
- External review information and forms
- Consumer help line: 800-300-5000
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in Maine?
Within 12 months of receiving a final decision on your appeal
Can I get a fast external review in Maine?
Decision within 72 hours of a completed request (without a hearing) when the standard timeline would seriously jeopardize life, health or ability to regain maximum function. You may apply for expedited external review at the same time as an expedited internal appeal; not available once services have been rendered.
Does external review cost anything in Maine?
Free (no filing fee; the insurer pays the cost of the review)
Do Maine’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- Maine Bureau of Insurance: Complaints/Appeals/External Reviews
You must request an external review within 12 months of receiving a final decision on your appeal.
- 24-A M.R.S. §4312 Independent external review
An enrollee may not be required to pay any filing fee as a condition of processing a request for external review.
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.