Independent Dispute Resolution - Out-of-Network Care Provider Form

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

Provider
Prefix
Person completing this form
Prefix
Patient Name
Prefix
Insurance Company
Is this Insurance plan fully-funded?
Please provide the following to Insurance.PFR@maine.gov or send a fax to (207)-624-8599.

  1. the provider’s level of training, education, and experience:

  2. an explanation of the circumstances and complexity of the particular case, including time and place of the service:

  3. individual patient characteristics, if relevant:

  4. the provider’s usual charge for comparable services rendered to uninsured patients, patients treated on an out-of-network basis, patients treated under contracts with other carriers or self-insured plans, and, if applicable, patients treated under a contract with the carrier or plan involved in the dispute that was terminated or that expired within one year before the date the service was rendered:

  5. any other relevant information:

Attestation:

By signing this application, I hereby agree to be bound by the outcome of the IDR, to submit to the jurisdiction of the Superintendent and the courts of this State, and to refrain from billing the patient more than the applicable out-of-pocket costs permitted by 22 M.R.S. §1718(D)(2). I also attest that the information provided herein is true and accurate to the best of my knowledge.