Public Law 2022 Chapter 603, effective August 8, 2022, requires that a carrier which is unable to make a provider credentialing decision within 60 days of receiving a completed application must apply to the Maine Bureau of Insurance, prior to the end of the 60-day period, to request an extension. In the application, the carrier must explain why the credentialing decision is taking longer than permitted. If the problem is not specific to a particular application, the carrier must submit for approval a remediation plan to bring its credentialing process in compliance with the 60-day statutory time limit.
Complete the Maine Carrier Credentialing Extension Application
There are two options for completing the Credentialing Extension Application. Complete and submit it online or print out the paper form, fill it in, and send it to the Maine Bureau of Insurance.
Supporting documents may not be sent with the online form. These documents may be sent by mail, fax or e-mail. See details below.
Printable Form Option:
- Maine Carrier Credentialing Extension Application Paper (Printable Form)
Printable forms may be send by mail, fax or e-mail. See details below.
Details for Sending Printable Form and Supporting Documents to the Maine Bureau of Insurance. If additional space is needed, please use a separate sheet of paper.
By Fax: (207) 624-8599 - Please include your name and the words: "Provider Credentialing Extension Application" on the fax cover page.
By E-mail:* firstname.lastname@example.org - Please include your name and the words " Provider Credentialing Extension Application " on the subject line.
By Regular Mail: Send the form to the Bureau's mailing address below. Please include your name and the words " Provider Credentialing Extension Application " on the envelope, or on its own page as the first page of the contents you are mailing. Supporting documentation sent by mail should be copies; PLEASE DO NOT SEND ORIGINALS.
Bureau of Insurance
34 State House Station
Augusta, ME 04333
*If you choose to send an electronic form, or documents by e-mail, the Bureau cannot guarantee the confidentiality of your information during electronic transmission. Once received by the Bureau your file will be confidential.
If you experience problems submitting the online forms, send an e-mail to PFR, Research.
If you have questions specific to the credentialing extension process, please contact Trish Nadeau at (207)-624-8416.