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
Applicant's Address *
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.


to pursue my appeal on my behalf.

Representative's Address
Section III - Insurance Plan Information
Insurer's Address *
Is the member’s insurance plan provided by an employer? *
Is the employer’s insurance plan self-funded? *

*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
Treating Provider's Mailing Address *

*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
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?
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?
Is your provider participating in the telephone 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.

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

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.