What is external review?
External review (also called independent external review) is a second level of appeal after the insurance company's internal process. In Maine, you file a written request with the Bureau of Insurance, which contracts with an approved independent review organization (IRO)to decide whether the carrier's denial was correct.
The program is governed by 24-A M.R.S. §4312. For eligible medical-necessity and similar disputes, the IRO decision is binding on the carrier. You cannot be charged a filing fee.
General overview: Appeals roadmap. Complete Maine internal appeals first unless an exception applies.
Who can use Maine review?
External review generally applies when:
- You have a Maine-regulated health plan
- The dispute involves medical necessity, pre-existing conditions, experimental/investigational treatment, or medical diagnosis/care/treatment (not simple "benefit not in the policy" issues)
- You exhausted internal grievance (or qualify for an exception under §4312(2))
Usually does not apply to:
- Self-funded ERISA employer plans
- MaineCare / Medicaid (fair hearing through DHHS)
- Medicare
- Plans not subject to Maine regulation (§4312(10))
Deadlines & exhaustion
12-month filing window
File a written external review request with the Bureau within 12 months of receiving a final adverse health care treatment decision after internal grievance (§4312(1)).
Exhaust internal appeals first
- Group plans: all internal grievance levels
- Individual plans: at least one internal level
Exceptions for expedited review when the carrier is late, health is at risk, or §4312(2) applies—see internal appeals guide.
How to file
- Complete internal appeals and keep the final adverse decision letter.
- Gather medical records, the denial letter, and your appeal correspondence.
- Submit the Bureau's external review application—online or by mail:
- Online External Review Application
- Bureau — complaints, appeals & external reviews (PDF form and guide)
- Check expedited review on the form if standard timelines would seriously jeopardize life, health, or maximum function.
- You may request a hearing and submit additional evidence; authorize release of medical records on the form.
Questions: Bureau Public Health Nurse Consultant (207) 624-8459 or consumer line 800-300-5000.
How long it takes
- Standard: IRO decision within 30 daysof the Bureau's receipt of a completed request ( §4312(5)(C))
- Expedited: within 72 hours when standard timing would seriously jeopardize life, health, or ability to regain maximum function (§4312(5)(D))
The carrier pays the cost of review to the Bureau (§4312(7)).
Is the decision binding?
Yes—for eligible cases, the external review decision is binding on the carrier (§4312(6)). You generally cannot request a second external review on the same adverse decision.
Judicial review and other legal remedies may still exist (§4312(9)). For ongoing insurer conduct issues, see Regulator complaints.
Medicaid & Medicare
MaineCare
MaineCare appeals use fair hearings through DHHS, not Bureau IRO review (MaineCare member resources).
Medicare
Use Medicare's appeal levels and CMS processes—see Medicare appeals.