New to helping someone in Maine?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan. Use the name and phone number on the card when you call or file paperwork (it may differ from an employer or clinic name).
- Denial letter or explanation of benefits (EOB)— the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline. On an EOB alone, search for words like "denied," "adverse determination," or "appeal."
- Summary of Benefits and Coverage (SBC) — a plain-language summary of what the plan covers. It helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (Marketplace, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter. Missing a deadline is one of the most common reasons people lose appeals they could have won.
Maine plans often use terms like adverse health care treatment decision or final adverse health care treatment decision. You usually appeal first with the insurance company (internal appeal or grievance). If that fails, you may request independent external review through the Maine Bureau of Insurance.
For steps that work in every state, read these general guides first, then return here for Maine rules:
- Denial decoder — what the denial letter is actually saying
- Appeals roadmap — internal appeal, then external review
- Building a strong appeal packet — records and letters to gather
What is different in Maine?
- CoverME.gov Marketplace: Maine runs its own Marketplace at CoverME.gov. The insurer on your ID card (Anthem, Harvard Pilgrim, Community Health Options, or Taro Health) handles prior authorization and appeals.
- Prior authorization (24-A §4304): Non-emergency PA often within the lesser of 72 hours or 2 business days; missing deadlines can mean the request is deemed approved.
- Internal appeals (24-A §4303): Carriers must maintain a grievance procedure; standard decisions often within 30 calendar days if you did not request an in-person hearing.
- Bureau external review (24-A §4312): Written request to the Bureau of Insurance within 12 months of a final adverse decision; IRO decision often within 30 days standard or 72 hours expedited; no filing fee; decision binding on the carrier.
- MaineCare (Medicaid): Fair hearing through DHHS—deadlines on your notice (often 60 days for service denials)—separate from commercial Bureau review.
Who is in charge of your plan?
The right agency depends on plan type. When in doubt, call member services and ask whether the plan is "fully insured in Maine" or "self-funded ERISA."
- Maine Bureau of Insurance (PFR): Fully insured health plans, external review, consumer complaints — maine.gov/pfr/insurance. Consumer line: 800-300-5000 (TTY 711).
- U.S. Department of Labor: Many self-funded employer plans.
- DHHS / MaineCare: Medicaid appeals and fair hearings — MaineCare member resources, Member Services 1-800-977-6740.
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.