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131st MAINE LEGISLATURE
FIRST SPECIAL SESSION-2023
Legislative Document No. 1498H.P. 953 House of Representatives, April 5, 2023
An Act to Create an Advocacy and Complaint Process for Health
Care Providers Within the Bureau of Insurance
Reference to the Committee on Health Coverage, Insurance and Financial Services
suggested and ordered printed.
ROBERT B. HUNT
Clerk
Presented by Representative PERRY of Calais.
Cosponsored by Representative O'NEIL of Saco, Senator LAWRENCE of York and
Representatives: DANA of the Passamaquoddy Tribe, GRAMLICH of Old Orchard Beach,
MATHIESON of Kittery, STOVER of Boothbay, Senator: CURRY of Waldo. Page 1 - 131LR1454(01)
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2 is amended to read:
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4 AND PROVIDER ASSISTANCE
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6 is enacted to read:
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8 The Health Care Provider Assistance Division, referred to in
9 this section as "the division," is established within the bureau. The division shall work in
10 coordination with other bureau sections and staff to accomplish the duties set forth in
11 subsection 4.
12 The Director of the Health Care Provider Assistance Division, referred
13 to in this section as "the director," is the head of the division. The director is appointed by
14 the superintendent and is subject to the approval of the Commissioner of Professional and
15 Financial Regulation. The director is subject to the Civil Service Law.
16 The superintendent may hire or assign personnel as determined necessary to
17 perform the duties of the division subject to the approval of the Commissioner of
18 Professional and Financial Regulation and subject to the Civil Service Law. The personnel
19 are supervised by the director in consultation with the superintendent. The qualifications
20 of those personnel must reflect the needs and responsibilities relating to the division's duties
21 under this subchapter.
22 The duties of the division include:
23 A. Providing access to the division through a toll-free number;
24 B. Providing information to providers regarding health plan coverage;
25 C. Assisting providers in navigating the health insurance industry;
26 D. Assisting providers with concerns specific to individual patients, such as denied
27 claims and prior authorization requests;
28 E. Addressing provider concerns on issues that may have a market-wide impact, such
29 as unnecessary credentialing delays and misapplication of accepted medical standards;
30 F. Assisting providers with complaints relating to licensees under the bureau that may
31 have violated a statute or rule;
32 G. Collecting and disseminating information regarding the activities of the division;
33 H. Submitting an annual report by January 1st of each year to the Commissioner of
34 Professional and Financial Regulation and the joint standing committee of the
35 Legislature having jurisdiction over insurance matters describing the activities carried
36 out by the division in the year for which the report is prepared, analyzing the data
37 available to the division and evaluating the problems experienced by providers; and Page 2 - 131LR1454(01)
1 I. Performing other duties as the superintendent may prescribe.
2 The following procedures apply to a complaint
3 submitted under subsection 4, paragraph F.
4 A. A provider requesting assistance or filing a complaint shall complete a grievance
5 form as prescribed by the division.
6 B. For a complaint or requests for assistance with concerns specific to individual
7 patients, the provider must submit a release of information form.
8 C. Upon receipt of the grievance form under paragraph A, the division shall investigate
9 the matter.
10 D. For complaints relating to individual patients that include a release of information
11 form, the division shall provide the provider a response that may include documents
12 relating to a patient's claim.
13 E. For complaints relating to individual patients that do not include a release of
14 information form, the division shall provide the provider a response limited to a
15 summary of the outcome of the investigation.
16 F. For complaints concerning issues that relate to violations of statutes or rules, the
17 division shall provide the provider a response that summarizes the division's findings.
18 G. If the complaint concerns issues that may have a market-wide impact, the division
19 shall refer the matters to the appropriate unit within the bureau and notify the provider
20 that the provider will be contacted further only if the unit requires additional
21 information.
22 H. An individual or entity that transacts insurance in this State or is otherwise subject
23 to the authority of the bureau shall, upon request of the division, provide the division
24 with all documents and information relevant to an investigation under this subsection
25 within 10 business days or any additional time as approved by the division for complex
26 matters.
27 I. The division may establish other procedures relating to the investigation of
28 complaints under this subsection.
29 Except as provided in this subsection,
30 documents and information from an insurer or a national association of insurance
31 commissioners, law enforcement agency or regulatory agency is confidential, is not subject
32 to a subpoena, is not subject to discovery or admission into evidence in a private civil action
33 and may not be the subject of testimony of the bureau. The bureau may:
34 A. Use documents and information obtained through an investigation under this section
35 as part of a regulatory or legal action brought as part of the duties of the bureau;
36 B. Share documents and information with other state, federal and international
37 regulatory agencies, including a national association of insurance commissioners, an
38 international association of insurance supervisors or a bank for international
39 settlements as long as the recipient agrees to maintain the confidentiality of the
40 documents and information;
41 C. Provide to a provider who made a complaint against an insurer a copy of the
42 insurance company's letter to the division in response to the complaint as long as that Page 3 - 131LR1454(01)
43 information does not interfere with a civil, criminal or administrative enforcement
44 proceeding; or
3 D. Disclose to the public the number of and nature of complaints and requests filed
4 with the division under this section.
5 The bureau may adopt rules to implement this section. Rules adopted
6 pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375,
7 subchapter 2-A.
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9 This bill establishes the Health Care Provider Assistance Division within the
10 Department of Professional and Financial Regulation, Bureau of Insurance to assist health
11 care providers in obtaining information about health insurance plans, assist health care
12 providers in navigating the health insurance industry, assist health care providers with
13 concerns specific to coverage for individual patients and issues that may have market-wide
14 impact and provide a system for health care providers to submit complaints about violations
15 of statutes or rules.
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