Specifications include, but are not limited to: The State of Maine Department of Professional and Financial Regulation, Bureau of Insurance is seeking proposals from Independent Review Organizations for furnishing all qualified personnel, facilities, materials and services to conduct independent dispute resolutions in Maine. An out-of-network provider who is unable in good faith to negotiate agreement with a fully-insured plan on the payment amount for emergency services within 30 calendar days; A person covered under a self-insured health plan that has opted into Maine’s independent dispute resolution process pursuant to 24-A M.R.S. § 4303-E (2) and Rule 365 § 6(7), and who has received a surprise bill for emergency services or a bill for covered emergency services rendered by an out-of-network provider; and An uninsured person who has received a bill from a provider for one or more emergency health care services rendered during a single visit totaling $750 or more. Independent dispute resolutions apply to the following types of bills: A surprise bill for emergency services received by an enrollee of a fully-insured health plan or a bill for covered emergency services that was rendered by an out-of-network provider; A surprise bill for emergency services or a bill for covered emergency services that was rendered by an out-of-network provider received by an enrollee of a self-insured plan that has opted into Maine’s independent dispute resolution process pursuant to 24-A M.R.S. § 4303-E (2) and Rule 365 § 6(7); and A bill totaling $750 or more received by an uninsured person for emergency health services. The independent dispute resolution process does not apply to bills received by enrollee for emergency services when the enrollee chooses the services of a specific provider knowing that the provider is out-of-network and the enrollee was informed of the opportunity to receive services from a network provider. Section 4303-E and Rule 365 requires the Bureau to oversee the independent dispute resolution process and to contract with qualified independent dispute resolution organizations to conduct independent dispute resolutions when requested. The independent dispute resolution is binding on the carrier, out-of-network provider, and the patient. The Bureau does not anticipate needing an electronic platform supplied by the Bidder to carry out the IDR process. The Bureau intends to manage receipt and screening of the cases for eligibility.
