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Maine External Review Summary
January 1, 2011 through December 31, 2011

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 2006 through 2009 are summarized by carrier in Figure 1.
The Bureau processed 39 qualified requests for external review during 2011. The carrier’s original decision to deny coverage was completely or partially overturned in 12 cases (31%), and upheld in 25 cases (64%). Two reviews were withdrawn because the carrier reversed its earlier decision and provided coverage.

The Bureau received additional requests for external review that did not qualify under the statute, either because the consumer had not exhausted the carrier’s internal appeal process or because the denial was based on issues other than validity of the carrier’s medical decisions.

Figure 1 illustrates the number of external reviews overturned, upheld, or withdrawn by either the carrier or consumer prior to the review for the years 2005 – 2011.

Figure 1.
External Review Outcomes
By Year

2011extrev

 

 


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Last Updated: August 22, 2012