MAINE BUREAU OF INSURANCE
PHYSICIAN PERFORMANCE MEASUREMENT,
REPORTING, AND TIERING PROGRAMS
2012 REGISTRATION FORM

General Instructions: Title 24-A MRSA §2694-A requires each insurer implementing or utilizing a physician performance measurement, reporting or tiering program to annually provide to the Superintendent a statement of the criteria, standards, practices, and procedures governing such a program. 

Please complete the following form within 60 days.  Applicants may be asked to provide such other information as the Bureau of Insurance may reasonably request. 

Null/Exempt Report

If the insurer believes that it is exempt from this requirement, or that it has nothing to report related to utilization of a physician performance measurement/reporting/tiering program, please state the reason in box # 1. Once this reason is described, the rest of the form need not be completed.

If you have questions about completing the form, please contact Joanne Rawlings-Sekunda at Joanne.Rawlings-Sekunda@maine.gov or 207/624-8472. 

General Information

Company Name

Contact Person
Phone Number
E-Mail Address

Federal ID Number

Physican Performance Measurement or Tiering Program Reporting Requirements (Summaries)

1.Please provide a very brief description of the physician performace measurement or tiering program(s).

2. Please provide a brief summary of the criteria used to measure physician performance or tier physician performance.

3. Please provide a brief summary of the standards used to measure physician performance or tier physician performance.

4. Please provide a brief summary of the practices and procedures used to measure physician performance or tier physician performance.

Physician Performance Measurement or Tiering Program Reporting Requirements (Full Statement)

5. In addition to the summaries in paragraphs 5 through 8, please provide full and true statements of: the criteria, the standards, and the practices and procedures used to measure physician performance or tier physician performance.  Please provide this information either via a link to its location on your website, or via PDF files.  As required by Title 24-A M.R.S.A. §2694-A(1), these statements must be verified by the oath of the insurer’s president or vice president, and secretary or chief medical officer, and the statements and supporting information are public records even if they might otherwise be protected as trade secrets or some other class of privileged information. 

Link to Website

Forward PDF Files to Research.PFR@Maine.gov