External Review Application

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

I am the: *

Patient

Physician

Legal Representative

Section I - Applicant Information

Patient's Name *

Patient's Date of Birth *

Patient's Mailing Address *

City/Town *

State/Province *

ZIP/Postal Code *

Patient's Email Address *

Patient's Phone *

* If different from Patient

Applicant's Name

Title / Relationship

Applicant's Mailing Address

City/Town

State/Province

ZIP/Postal Code

Applicant's Phone

Applicant's Email

Section II - 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 III – 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 IV – Health Care Decision in Dispute

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.

DO NOT INCLUDE MEDICAL RECORDS WITH YOUR APPLICATION.

You will have the opportunity to submit them directly to the Review Organization once the review is assigned.

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.

Health Care Decision *

Section V – 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 VI – 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:

VII – 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.

If you are an Authorized Representative requesting an external review on behalf of a patient, you have certain obligations to provide notice to that patient prior to filing this request for external review, and in the event that you decide to withdraw this request. By submitting this form, you hereby attest that you will comply with the notice requirements of 24-A MRSA § 4312(1-A).

Name of Patient / Applicant from section I *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