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Maine External Review Summary
January 1, 2013 through December 31, 2013


Maine 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, with no affiliation to 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. Years 2005 through 2013 are summarized by carrier in Figure 1.

In 2013, the CHCD received 36 requests for external review and processed 26 that were qualified; 24 were completed, as two were withdrawn by the consumers prior to hearing.  Of the 24 completed requests, 13 were upheld (54%), and 11 were overturned (46%).

Figure 1 illustrates the number of external reviews overturned, upheld, or withdrawn prior to the review (either by the carrier or the consumer), for the years 2005 – 2013.

 


Figure 1.
External Review Outcomes
By Year

Review Chart

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Last Updated: May 19, 2014