External Review Application

All fields with * after them are required fields. You cannot submit your report until all required fields are completed.

Section I - Applicant Information

Patient's Name *

Patient's Date of Birth *

Applicant's Name *

Applicant's Email Address *

Applicant's Address *

City/Town *

State/Province *

ZIP/Postal Code *

Applicant's Daytime Telephone *

Evening Telephone

Section II – Appointment of Authorized Representative

** Complete this section only if someone else is representing the patient in this appeal **

You may represent yourself or you may ask another person, including your treating health care Provider, to act as your personal representative. You may revoke this authorization at any time.

I hereby authorize: (Enter the name of the Authorized Representative.)

to pursue my appeal on my behalf.

Representative's Address

City/Town

State/Province

ZIP/Postal Code

Representative's Daytime Telephone

Representative's Evening Telephone

Section III - Insurance Plan Information

Member's Name *

Insurance ID *

Health Insurance Company's Name *

Insurer's Address *

City/Town *

State/Province *

ZIP/Postal Code *

Insurance Company's Telephone *

Is the member’s insurance plan provided by an employer? *

Yes

Name of employer *

Employer’s Phone Number *

Is the employer’s insurance plan self-funded? *

Yes

*If you are not certain, please check with your employer. Most self-funded plans are not eligible
for external review through the Bureau of Insurance. Please contact us for further information.

Section IV – Information about the Patient’s Health Care Providers

Name of Treating Health Care Provider *

Provider’s clinical specialty *

Provider's Address *

City/Town *

State/Province *

ZIP/Postal Code *

Treating Provider's Phone Number *

*If you have more than one treating provider that you would like to have participate in the
external review hearing, please provide a separate sheet listing their name, specialty, contact
information and times available for the hearing. Email the sheet to Violet.M.Hyatt@maine.gov

Section V – Health Care Decision in Dispute

Describe the health insurance company’s decision in your own words. Include any information
you have about the health care services, supplies or drugs being denied, including dates of
service or treatment and names of health care providers. Explain why you disagree.

Please email the following to Violet.M.Hyatt@maine.gov

Additional pages, if necessary.

A copy of the Health Insurance Company’s letter denying the requested treatment or service at the final level of the company’s internal appeals process.

If possible, a statement from the treating health care provider indicating why the disputed service, supply, or drug is medically necessary.

Health Care Decision *

Section VI – Expedited Review

** Complete this section, only if you would like to request expedited review **

The patient or appointed representative may request that the external review be handled on an
expedited basis. To qualify for an expedited review, the delay must seriously jeopardize the life
or health of the patient or would jeopardize the patient’s ability to regain maximum function.
Expedited external review is not available when services have already been rendered.

Do you request an expedited review?

Yes

Section VII – Request for a Hearing

** Complete this section, only if you would like to request a telephone hearing **

If the patient, the authorized representative or the treating health care provider would like to
discuss this case with the Independent Review Organization and the insurer in a telephone
conference, select “Yes” below.

Do you request a telephone hearing?

Yes

Is your provider participating in the telephone hearing?

Yes

*If yes, please provide the provider’s contact information and times available for the hearing:

VIII – Authorization and Release of Medical Records

I hereby authorize that any hospital, physician, insurance carrier or insurance carrier
subcontractor;, or any entity regulated by the Maine Bureau of Insurance may furnish the Bureau
and the Independent Review Organization (IRO) assigned to review the insurance carrier’s
adverse health care treatment decision with any medical information or records that may be
required to conduct the external review. I specifically authorize the release of information
concerning mental health, and substance abuse treatment if that information is needed to conduct
the external review.

Name of Patient / legal representative or authorized representative from section II *Please specify relationship or title *

The time frame for receiving a decision from an IRO for a standard external review is up to 30
days.

Expedited external review is available only if adherence to the time frame for standard review
would seriously jeopardize the life or health of the covered person or would jeopardize the
covered person’s ability to regain maximum function. The time frame for receiving a decision
from an IRO for an expedited external review is within 72 hours without a hearing.

Maine.gov

Office of the Maine State Treasurer

External Review Application