The Maine Bureau of Insurance Consumer Health Care Division

• Do you need help with a complaint against your health insurance carrier?
• Are you frustrated because you can’t get an answer to your health insurance questions?
• Do you want to know which health insurance carriers are selling health plan products in Maine?
• Would you like someone to speak to your group about health insurance?

 

Contact:
Consumer Health Care Division
Maine Bureau of Insurance
34 State House Station
Augusta, Maine 04333

1-800-300-5000 (in Maine) or
207-624-8475

TDD 1-888-577-6690

www.maine.gov/insurance

We can help!

 

The Consumer Health Care Division staff assists consumers on the phone, by email, in person, or by mail. We can:

• Explain your rights as a health care consumer
• Answer your questions about health insurance
• Help you to understand what your health care plan covers and
• Assist you when you have a problem or complaint.

 

In 2002, the Bureau’s Consumer Health Care Division was able to obtain approximately $910,500 in the form of health claims paid or money actually returned to consumers.

Did you know that you have the right to receive the following information from your health insurance carrier?

• The areas of the state served by the insurance plan
• How to select your primary care physician
• Which benefits are excluded or limited
• How to access specialty care
• Benefits available when you’re away from home
• Emergency room coverage and requirements
• Out-of-pocket expenses
• What the “maximum allowable” or “usual and customary” reimbursement the carrier will pay for a procedure
• Provisions for continuity of care and
• An explanation of the process for disagreeing with the carrier’s decisions on your care.

Other rights that you have:

• To receive coverage for emergency services when a “prudent person” would reasonably believe that your condition is serious enough to require emergency medical attention.
• To apply for a standing referral from your primary care physician when you have a condition that needs ongoing care from a specialist.
• To appeal decisions made by your health insurance carrier. If your company denies a requested service, they must explain their decision in writing.
• To know who is making medical decisions about you at the insurance company. Ask the company to send you a list of names, titles, and qualifications of these people.
• To have help when you disagree with your insurance company. A relative, friend, doctor, or nurse may be willing to help. Also, you always have the right to call the Bureau of Insurance for help.

 

How Do I File a Complaint Against My Health Plan?

• First file an appeal directly with the insurance company.
• If the appeal is denied, request a second level appeal with the insurance company.
• If the denial is based on whether the care is medically necessary, you can request an independent external review through the Maine Bureau of Insurance. (An external review is an additional step to appeal when the insurance company denies paying your health insurance claim.) You can call the Bureau at 800-300-5000 (in Maine) or (207) 624-8475 for more information on this process or view our Internet brochure, Guide to Requesting an External Review located at on our Web page.
• If you don’t feel comfortable dealing with your insurance carrier, you can file a complaint at any time with the Consumer Health Care Division in the Bureau of Insurance.
• Complaints filed with the Consumer Health Care Division can be filed by mail, email or by using the on-line complaint form. If you want to send additional documents, please keep the originals and send only copies.
• When we receive your complaint, we will send you a written notice that we are investigating the complaint along with the assigned file tracking number. It is helpful if you refer to the file number if you call for an update on the investigation.
• When we receive a response from the company, we will review it and take one of the following actions:
• If the complaint has been resolved in your favor, we close the file and inform you of the resolution.
• If an insurance law has been violated, we direct the company to take corrective action.
• If the company is not following the terms of the policy, we direct them to take corrective action.
• If the company has not responded to all the questions raised in the complaint, we will require them to do so.
• If we find there is no violation of Maine law we will tell you why the investigation is being closed.

 

October 2003