Data Reporting Requirements

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286-A (Supplemental Health Insurance Reporting Form)

• Bulletin 286-A (PDF)
• 286-A Report Form (XLSX)
• 286-A Instructions (PDF)
• Edit Checks (PDF)

940 (Health Insurance Annual Data Report)

• Rule 940 (DOCX)
• Rule 940 Report Form (XLSX)
• Rule 940 Instructions (PDF)

945 (Maine Annual Report Supplement)

• Rule Chapter 945 (DOC)

Short Form - Completed by companies with less than $5 million in direct written Health insurance premium for major medical and stop loss combined

• 945 Report Short Form (XLSX)
• 945 Short Form Instructions - For companies completing the 945 Short Form (PDF)

Long Form - Completed by companies with $5 million or more in direct written Health insurance premium for major medical and stop loss combined

• 945 Report Long Form (XLSX)
• 945 Long Form Instructions - For companies completing the 945 Long Form (PDF)
• 945 Long Form Edit Checks - For companies completing the 945 Long Form (XLSX)

Aggregate Workers' Compensation Benefits Paid Report

Insurance Carrier Aggregate Benefits Paid Report

• Carrier Workers' Compensation Aggregate Benefits Paid Report Form (XLSX)
• Instructions (PDF)
• Title 26 Chapter 4 §61
• Search for Maine License Number

Self-Insurance Aggregate Benefits Paid Report

• Self-Insurance Aggregate Benefits Paid Report (XLSX)
• Instructions (PDF)
• Title 26 Chapter 4 §61(1-A)
• Search for Maine License Number

Any Willing Pharmacy - Bulletin 377

• Any Willing Pharmacy Requirements (PDF)
• Any Willing Pharmacy Report Form (DOCX)
• Bulletin 377 (PDF)
• Title 24-A Chapter 56-A §4317
• Title 24-A Chapter 32 §2673-A(3)

Carrier Report

• Carrier Report Form (XLSX)
• Carrier Report Instructions (PDF)

          TPA page

Comparable Health Care Service Incentive Program Report 

Only carriers offering small group plans compatible with a Health Savings Account should file this report. Notices will be sent to those companies that must file it.

• Comparable Health Care Service Incentive Program Report Form (XLSX)
• Comparable Health Care Service Incentive Program Report Instructions (PDF)

Credit Disability Insurance Experience Report

• Credit Disability (XLSX)

Credit Life Insurance Summary Report

• Credit Life (XLSX)

Cybersecurity Information

• Notification of Cybersecurity Event Forms

Dental Loss Ratios

Only Companies offering a dental plan in effect during the preceding calendar year should file these reports.

• Dental Loss Ratios Report Form (XLSX)
• Instructions (PDF)
• 24-A M.R.S. § 4319-B (6)

Employee Benefit Excess Insurance

Only Companies with written premium for Stop Loss should file this report. Notices will be sent to those companies that must file.

• Employee Benefit Excess Insurance Report Form (XLSX)
• Instructions (PDF)
• Rule 135 (DOCX) 
• Title 24-A Chapter 9 §707(3)

Fraud and Abuse Annual Report

• Fraud and Abuse Report Form (XLSX)
• Instructions (PDF)
• Rule 920 (DOCX) 
• Title 24-A Chapter 23 §2186
• Search for Maine License Number

Health Plans Providing Prescription Drug Benefits Report

Only carriers that issue health plans with prescription drug benefits need to complete this form.

• Health Plans Providing Prescription Drug Benefits Report Form (XLSX)
• Instructions (PDF)

Health Report Card Survey

• Health Report Card Survey Form (PDF)

Liquor Liability

• Liquor Liability Report Form (XLSX)
• Instructions (PDF)
• Bulletin 149 (PDF)
• Title 28-A Chapter 100 §2517
• Search for Maine License Number

Long-Term Care Insurance Reporting (Rule 425)

• Rule 425 (DOCX)
• Long-Term Care Report Form (XLSX)
• Instructions (PDF)
• Search for Maine License Number

Mandated Benefits

• Mandated Benefits Report Form (XLSX)
• Instructions (PDF)

Medical Malpractice Liability Claim Report

Please EMAIL the report form to the address at the bottom of the document. The current version of the form is dated 6/20/2020

• Liability Claim Report Form (DOCX)
• Instructions for Claim Report (PDF)
• Title 24 Chapter 21 §2601

NQTL Reporting Requirement - 24-A M.R.S. § 4320-T(4)

• NQTL Report Form (DOCX)
• NQTL Report Form Instructions (PDF)
• Guidance for NQTL Comparative Analyses (PDF)

Physician Tiering

• Physician Performance Measurement, Reporting and Tiering Programs - Registration Form
• Title 24-A §2694-A

P.L. 2023 Chapter 680 Report (Prior Authorizations)

• Prior Authorizations History Report (XLSX)
• Instructions (PDF)

Self-Insurance Annual Payroll and WC Aggregate Benefits Paid Reports

Self-Insurance Annual Payroll Report

• Self-Insurance Annual Payroll Report (XLSX)
• Instructions (PDF)
• Title 39-A Chapter 9 §409
• Search for Maine License Number

Self-Insurance Aggregate Benefits Paid Report

• Self-Insurance Aggregate Benefits Paid Report (XLSX)
• Instructions (PDF)
• Title 26 Chapter 4 §61(1-A)
• Search for Maine License Number

Tickborne Disease Report

• Tickborne Disease Report (XLSX)
• Instructions (PDF)
• Title 24-A Chapter 56-A §4302(5)

Title 24-A M.R.S. § 4303-E Report (Denials, Downcoding, Network Data)

Applies only to health carriers with more than 1,000 Maine covered lives as reported in reports required by Rules 940 and 945. 

• Title 24-A M.R.S. § 4303-E Report (XLSX)
• Instructions (PDF)
• Title 24-A M.R.S. § 4303-E 

Workers' Compensation Insurance Market Survey

• WC Insurance Market Survey Report Form (XLSX)
• Instructions (PDF)

The documents on this page are also available in hard copy by contacting the Bureau.