Maine Department of Professional and Financial Regulation - Bureau of Insurance

http://www.maine.gov/pfr/insurance/producer/licforms.htm

Varies by insurance type. Baseline of $45

http://www.maine.gov/pfr/insurance/producer/licforms.htm

Varies by insurance type. Baseline of $45

Biennially

From $25 to $165 depending on license type

Medical Utilization Review License Application

$400

• For foreign applicants, proof of registration with the Maine Secretary of State.
• A list of all states in which applicant is licensed to perform similar services, including current license numbers.
• A list of all principal proprietors, partners, directors, officers and administrators.
• Provide number of applicant's employees in Maine and estimated number of employees nationally. If operations are conducted at more than one location in Maine, list locations and activities separately and give number of employees at each location.
• A detailed description of the medical utilization review processes in place for each medical utilization review program
  offered by the applicant, including but not limited to:
  • A. Second opinion programs.
  • B. Hospital pre-admissions certification.
  • C. Pre-inpatient service eligibility determination.
  • D. Concurrent hospital review to determine appropriate length of stay.
  • E. Notification of covered persons and providers of utilization review decisions.
  • F. Other (explain).
• A description of the processes used by the applicant to address beneficiary and provider requests for reconsideration, standard appeals, expedited appeals, and second level grievance reviews.
• A copy of all materials to be used by the applicant to inform beneficiaries of the requirements of the utilization review plans and the rights and responsibilities of the beneficiaries under the plan.
• Copies of any policies and procedures the MUR entity has in place for use with their medical utilization review criteria.
• A statement of whether the MUR entity has developed its own medical utilization review criteria, or whether it has contracted with any other entity to provide the MUR entity with review criteria. If the MUR contracts with another entity for criteria, a copy of the contract or license agreement, including the contract or agreement expiration date must be provided.
• A description of the applicant's process for preserving the confidentiality of medical information used in the utilization review process.

$100

Annually by April 1.

Return the notice sent by the insurance bureau along with the renewal fee to renew your license.

Annual Evaluation Information Reporting Form

$0

Annually by April 1.

• UREs that have completed the Bureau of Insurance Annual Report Card need not complete this form.
• Any insurer or 3rd-party administrator which issues or administers a program or contract in this State providing coverage for hospital care that contains a provision whereby in non-emergency cases the insured is required to be prospectively evaluated through a pre-hospital admission certification, pre-inpatient service eligibility program or any similar pre-utilization review or screen eligibility program or any similar pre-utilization review or screening procedure prior to the delivery of contemplated hospitalization, inpatient or outpatient health care or medical services which are prescribed or ordered by a duly licensed physician shall file a report on the results of that evaluation for the proceeding year with the superintendent

Online

$55

Online

$75

Online

$60

By April 1 of odd-numbered years.

Online

$85

Online

$70

By April 1 of odd-numbered years.

Online

$25

Online

$45

Online

$30

By December 1 of even-numbered years.

Online

$45

Online

$30

By December 1 of even-numbered years.

Registration Application for Service Contract Provider and Service Contract Administrator

Mail

$200

Registration Application for Service Contract Provider and Service Contract Administrator

Mail

$200

Annually by November 1.

TPA Registration Application 

TPA Application Checklist 

Mail 

$100

TPA Contract Certification, TPA Bond Form, verification of applicationfor registration with Maine Secreatry of State.

Complete instructions for renewal payment and bond calculation are included within the renewal notice.

Mail

$100

Annually by May 1. Reporting Form is due annually by April 30. 

Bond Calucation Form and Reporting Form.