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Independent External Review

Health Guide Ranking

Utilization Review Requests, Decisions, and Appeals Independent External Review
Health Guide Complaints Health Guide Contacts Health Guide

 

Four performance areas are presented in this Interactive Guide. Select from the toolbar above to view each of the comparative charts. Below each chart is a description on how to read and understand the results.

INDEPENDENT EXTERNAL REVIEW (2006 through December 2010)

Maine law gives consumers the right to request an independent external review when a health insurance carrier (insurance company or HMO) denies benefits for health care services. Consumers are entitled to an external review when benefits are denied based on issues involving medical diagnosis, care or treatment, medical necessity, preexisting conditions, or denial of services because the insurance carrier considers the treatment to be experimental or investigational.

Before consumers request an external review, they must exhaust the health insurance carrier's first and second level appeal and grievance process as described in their policy. For information regarding how to request an independent external review, the Bureau provides an on-line brochure called "Guide to Requesting an Independent External Review" which can be accessed at: www.maine.gov/pfr/insurance/external_review.htm.

The Bureau processed 26 qualified requests for external review during 2010. Of these cases, 13 (50%) were completely overturned (the carrier’s original decision to deny coverage was entirely reversed), and 12 (46%) upheld the carrier’s decision. One request for an external review was withdrawn by the carrier before the external review was conducted.

Additional requests for external review were received that did not qualify as eligible under the statute, either because the denial was based on issues other than validity of the carrier’s medical decisions or the policy was self-funded and therefore did not qualify for review under Maine law. Some of the external reviews included in this chart are from companies who are no longer selling new policies in Maine and therefore are not listed in this booklet.

External Review Outcomes By Year

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Last Updated: August 22, 2012