Emergency Services and Surprise Bills

A surprise bill is a bill you receive for covered services performed by an out-of-network (non-participating)  health care provider in the following circumstances:

• A surprise bill for emergency services;
• Any other bill for covered emergency services rendered by an out-of-network provider to a person covered by an insured or self-insured health plan; and
• A bill totaling $750 or more received by an uninsured person for emergency health services if the total bill for the single visit is $750 or more regardless of the number of providers included in the bill.
• If your plan does not require referrals, a surprise bill only occurs in limited circumstances. For example, when during your office visit a network doctor brings in an out-of-network provider or sends bloodwork to an out-of-network laboratory without your written consent.
• A surprise bill does not include a bill for health care services when you knowingly elect to see an out-of-network provider.

For either a surprise bill or emergency services, you will only be responsible to pay your in-network deductible, co-pay or co-insurance amount. We may initially pay the claim at the out-of-network level until further information is provided.

If you receive a bill from an out-of-network provider and believe it is a surprise bill or a bill for emergency services, do not pay the provider. Call the phone number on your health plan ID card. We may request that you submit additional information needed to determine whether it is a surprise bill.  We may attempt to negotiate with the provider or pay an additional amount to resolve the claim. If we pay more, your cost share will not increase.

If the provider disagrees, the provider may submit the dispute for review through Maine’s independent dispute resolution process. After the dispute is resolved, your cost share will not increase if the health plan is told they must pay additional amounts.

Maine will select an independent dispute resolution entity (IDRE) to review claims for emergency services and surprise bills where the payment amount can’t be agreed upon. The IDRE will receive information about the services received and determine the reasonable fee for the services. The IDRE will issue a decision accepting either our payment amount or the provider’s billed charge. For surprise bills, a dispute may be submitted to the IDRE for review by a health care plan  including a participating self-insured health plan, an out-of-network physician, facility, uninsured patient and a person covered under a nonparticipating self-insured health plan who has received a surprise bill for emergency services or a bill for covered emergency services rendered by an out-of-network provider, and did not knowingly elect to obtain the services from an out-of-network provider.

To submit a dispute for review by the independent dispute resolution entity (IDRE) fill out the application that can be found on the Maine Bureau of Insurance Website  https://www.maine.gov/pfr/insurance/index.html.