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Maine External Review Summary
January 1, 2009 through December 31, 2009

The law gives consumers the right to an independent external review after exhausting the internal appeals options within their health insurance company. It is called an “independent external” review because the Bureau of Insurance arranges to have a contracted review organization which has no affiliation with the insurance carrier, conduct the review. The decision of the external review is binding only on the carrier.

External Reviews became available for health insurance enrollees in Maine in 2000. The first request for an external review was received by the Bureau of Insurance in August, 2000. Since it began and until the end of 2009, 190 external reviews have been processed and completed. Years 2006 through 2009 are summarized by carrier in Figure 1.

Figure 1.

In 2009, 17 qualified requests for external review were processed. Of these 17 reviews, five (29%) were completely overturned (the carrier’s original decision to deny coverage was entirely reversed), two reviews (12%) resulted in a partial overturn of the denial, nine (53%) upheld the carrier’s decision and one review was withdrawn prior to completion (6%) with a favorable outcome for the consumer.

Figure 2. illustrates the number of external reviews that were overturned, upheld or withdrawn by either the carrier or consumer prior to the review, for the years 2006 through 2009.

Figure 2.

External Review Outcomes
By Year

To qualify for external review in Maine, the denied benefits issue being disputed by the consumer must relate to one of the following: medical necessity, pre-existing condition exclusion, experimental or investigational treatment, or medical diagnosis/care/treatment. In 2009, 16 cases (94%) related to medical necessity, and one case (6%) to a pre-existing condition exclusion.

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