What is prior authorization?
Prior authorization (PA)—also called preauthorization—means the health plan must approve certain care before it will cover it. Doctors or hospitals often submit PA for you, but you still have rights if PA is denied.
A PA denial is different from a bill denial after care already happened. With PA, the fight is usually about whether the plan will allow the treatment at all.
Overview for any state: Prior authorizations. This page is Maine-only.
Confirm plan type: Maine: Start Here.
Maine PA rules
Maine's utilization review and PA standards are in 24-A M.R.S. §4304 (Health Plan Improvement Act). Carriers remain responsible even when a vendor performs review.
Non-emergency prior authorization
- Decision within the lesser of 72 hours or 2 business days after the carrier receives a complete request
- Same timeline after the carrier receives additional information or completes outside consultation
- Both the provider and enrollee must be notified of the determination
If the plan misses PA deadlines
If the carrier does not grant or deny PA within the required time frames, the provider's request is deemed granted (§4304(2)).
Other protections
- No PA for emergency services and no PA for post-evaluation or post-stabilization services during the same emergency encounter (§4304(5))
- Post-stabilization inpatient review: decision within 24 hours or services deemed approved until the carrier notifies the provider otherwise (§4304(5)(C))
- Services within 14 days before or after an approved PA date generally cannot be denied solely for timing (§4304(2)(E))
- Non-emergency claims generally cannot be denied only for lack of PA if medical necessity review is still pending; provider penalty capped at 15% of allowed amount (§4304(2)(F))
- No PA for medication-assisted treatment for opioid use disorder (with limited exceptions) ( §4304(2-A))
- Appeals of adverse treatment decisions reviewed by a clinical peer not involved in the initial denial ( §4304(7))
Prescription drugs
Formulary exceptions and clinically appropriate drug requests follow §4304 and 24-A M.R.S. §4311—often 72 hours or 2 business days standard, 24 hours for exigent circumstances.
Where to look up PA rules
Each carrier publishes PA criteria and submission methods. Use the links on Maine: prior auth & internal appeals links or call the number on the member ID card.
CoverME.gov plans: Anthem, Harvard Pilgrim, Community Health Options, and Taro Health are the major individual/family carriers approved in Maine (Bureau — individual & family coverage).
MaineCare
MaineCare has its own authorization and appeal rules through the Office of MaineCare Services. Service denials: request a fair hearing as explained on your notice—see MaineCare member resources and Maine internal appeals.
If PA is denied
A PA denial is an adverse health care treatment decision. Appeal through the carrier's grievance process first. Your notice must explain internal and external review rights (24-A M.R.S. §4303).
Urgent care
Emergency services cannot require PA first. For urgent non-emergency situations, ask the provider to certify urgency and request expedited internal and, if needed, external review. Maine law allows skipping internal grievance in some expedited external review cases (24-A M.R.S. §4312(2)).