Maine State Out-of-Network Surprise Medical Bill

You may not be responsible for a surprise bill.

For out-of-network services

A “Surprise Bill” is when you have insurance coverage issued in the State of Maine and defined as:

Hospital or Surgical Centers: You are a patient at a participating hospital or ambulatory surgical center and you receive services for which:

  • A network provider was not available; or
  • An out-of-network provider provided treatment without your knowledge.

However, if you chose to receive services from an out-of-network provider instead of from an available network provider, or if you chose to receive transportation from an out-of-network ambulance service, then your bill for those services is not a “Surprise Bill.”

In the event your plan and an out-of-network provider cannot agree on a reasonable fee for services, then the disagreement (what is known as a “fee dispute”) may be eligible for independent dispute resolution (IDR), as provided for pursuant to [insert citation to relevant Maine law; Amanda can provide]. Under Maine law, you, your provider or your plan may apply for IDR. If a case qualifies for IDR, a State-approved qualified provider in the relevant specialty will review evidence submitted by the IDR applicant and the other party to the fee dispute. The IDR decision is final and binding.

How to Submit a Fee Dispute to IDR.

The State of Maine uses a secure system called “Maximus Federal” to process applications for IDR. You can log on to https://dispute.maximus.com/me/indexME to create an account and complete the form for electronic submission. To submit the form electronically, you must have an email address. If you do not have an email or do not wish to create an electronic account, you may contact Maximus Federal toll-free at: (888) 866-6205.

Whether you contact Maximus Federal electronically or by toll-free telephone, you can speed the application process by gathering the following information: Copies of any bills; copies of any claim forms; copies of any Explanation of Benefits (EOB); any other relevant communications between patient, provider, and/or carrier you wish the Independent Dispute Review Entity to consider; and, importantly, the actual dollar amount you will accept in full resolution of the fee dispute.

For more information on the State of Maine IDR process, please contact Maximus Federal, the Maine Bureau of Insurance ((800) 300-5000) or Wellfleet at (800) 633-7867. The IDRE will decide within 30 days. The arbitrator will issue a written decision within 30 calendar days after receiving a completed application.

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