Maine gives you a full year to ask for external review

Twelve months, from the second-level denial

Two things make Maine's clock different. The window is 12 months rather than four, and it runs from the denial of the SECOND-level appeal — because Maine's internal process has two levels rather than one. A first-level denial does not start the count, which is worth confirming before assuming a case has been sitting too long.

How the Bureau starts the file

Maine begins with contact rather than paperwork. You call or write the Bureau of Insurance to request an external review; once the Bureau determines that you qualify, it sends you a packet containing an authorisation and a contact sheet. You complete the contact sheet, sign the authorisation, and return them with a copy of the second-level appeal denial letter from the insurer.

• Request the review by calling or writing to the Bureau of Insurance.
• The Bureau confirms eligibility and sends the packet.
• Return the completed contact sheet, the signed authorisation, and the second-level denial letter.
• The application can also be filed through the Bureau's online external review form, or by mailing the PDF version.

Thirty days for the decision

The external review organization must complete the review within 30 days after it first receives the case, and a written decision goes to the consumer and to the carrier. Maine's Rule Chapter 850 sets out how these appeals are conducted and the deadlines for responding to consumers along the way.

How to file

1. 1

   Finish both internal levels

   Maine's internal process runs two levels; the external clock starts when the second-level appeal is denied.

2. 2

   Contact the Bureau

   Call or write the Bureau of Insurance to request the external review — this is the step that opens the file.

3. 3

   Complete the packet the Bureau sends

   A contact sheet to complete and an authorisation to sign, returned with the second-level denial letter.

4. 4

   Or file online

   Maine also publishes an online external review application and a mailable PDF form.

The rules behind the process

The statutory basis is 24-A M.R.S. 4312, independent external review, and the operational detail lives in Rule Chapter 850. The Bureau also publishes a consumer guide to requesting an external review and, in Bulletin 265, guidance on utilization review determinations — worth reading where the dispute is about how the determination itself was made rather than about the medicine.

Prior authorization and step therapy: miss the clock, grant the request

Maine puts short deadlines on the front end and attaches a real consequence to missing them. For a non-emergency service a carrier must answer a provider's prior-authorization request within 72 hours or two business days, whichever is less (24-A M.R.S. 4304). The step-therapy override rules at 24-A M.R.S. 4320-N run on the same clock, with 24 hours where exigent circumstances exist — and if the carrier or utilization review organization does not grant or deny in time, the exception or appeal is granted.

• The required drug is contraindicated, or will likely cause an adverse reaction.
• It is expected to be ineffective given the enrollee's clinical characteristics.
• The enrollee already tried it — or a similar drug — and it was discontinued for lack of efficacy or an adverse reaction.
• It is not in the enrollee's best interest based on medical necessity.

For Maine practices

The generous window changes what is worth revisiting. A practice that clears out aged denials on a four-month assumption will be discarding Maine cases that remain fully eligible. It is worth running a periodic sweep of Maine second-level denials from the past year, since the cost of checking is small and the right survives far longer here than anywhere else.