CurrentAetnaPolicy N/A

Maine surprise billing and emergency services IDR process

Explains how Aetna handles surprise bills and covered emergency services for members subject to Maine law, including member actions, payment responsibilities, and Maine's Independent Dispute Resolution (IDR) process. Applies to members in health plans governed by Maine regulations.

Policy Summary

PayerAetna

PolicyMaine surprise billing and emergency services IDR process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf a provider disagrees with payment for covered emergency services, initiate Maine's IDR process via the Maximus portal or by calling 1-888-866-6205.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysIDR arbitrator decision timeframe

$750IDR monetary threshold

1-888-866-6205Maximus phone

Oct 1, 2020IDR effective on or after

Coverage and Surprise Billing Rules

Coverage criteria and IDR process

When a surprise bill or covered emergency services bill is covered and what the member should expect:

Applies to members in health plans subject to Maine law.

A surprise bill is a bill for covered services, including emergency services, from an out-of-network (non-participating) provider that the member did not knowingly choose. This can occur during a service at a participating hospital or emergency facility, during a previously authorized service, or when an out-of-network provider is involved without the member's written consent.

Not considered a surprise bill when

A network provider was available but the member chose to get services from a non-network provider.

If you receive a surprise bill or a bill for covered emergency services, do not pay the bill. Call the toll-free number on the back of your member ID card and provide any requested documents so Aetna can review and may negotiate with the provider or pay an extra amount; if Aetna pays more, your cost share will not increase.

Policy Summary

PayerAetna

PolicyMaine surprise billing and emergency services IDR process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf a provider disagrees with payment for covered emergency services, initiate Maine's IDR process via the Maximus portal or by calling 1-888-866-6205.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Cost sharing for surprise bills and covered emergency services is limited to the member's in-network deductible, copayment, or coinsurance amount.

If an out-of-network provider disagrees with Aetna's payment for covered emergency services, the provider may pursue Maine's Independent Dispute Resolution (IDR) process administered by Maximus Federal Services; if IDR results in additional payment, the member's cost share will not increase.

IDR scope and exclusions

Eligible: A surprise bill for emergency services or any bill for covered emergency services from an out-of-network provider to a member of an insured or self-insured plan.
Not eligible: Services the member knowingly chose to receive from an out-of-network provider.
Not eligible: Ambulance services covered by a health plan.
Not eligible: Disputes where the difference between the provider's billed charge and the median network rate is less than $750.

Who may apply for IDR

Members whose claims meet criteria: covered under a self-insured/ERISA plan that doesn't participate in IDR (check plan documents), involve a surprise bill for emergency care or covered emergency services from an out-of-network provider, and the member did not knowingly choose the out-of-network provider.
Out-of-network providers whose claims meet criteria: associated with a self-insured/ERISA plan that does participate in IDR or a fully insured Maine plan, and involve a surprise bill for emergency care or covered emergency services from an out-of-network provider.

How to start IDR

Online: Create an account and submit an application through the Maximus portal.
By phone: Call Maximus at 1-888-866-6205 to start the process. Applicants should be prepared to provide bills, claim forms, EOBs, communications, and a dollar settlement figure.

Adjudication timeline: Maximus assigns an arbitrator who will issue a written finding within 30 days of receiving a completed IDR application.

IDR Eligibility Threshold

IDR eligibility monetary threshold -- inv-02

IDR monetary eligibility thresholdDifference between provider's billed charge and the median network rate must be greater than or equal to $750 to be eligible for IDR.

Ineligible when difference is below thresholdIf the billed-to-median-network-rate difference is less than $750, the bill is not eligible for Maine's IDR process.

Applies to disputes over covered emergency servicesThis threshold is used to determine eligibility for IDR in disputes involving covered emergency services from out-of-network providers.

How Providers Initiate Disputes

Prior Authorization

Initiate Independent Dispute Resolution (IDR)

Providers may initiate Maine's Independent Dispute Resolution (IDR) process administered by Maximus to resolve payment disputes for covered emergency services from out-of-network providers. Start the IDR promptly after attempting plan-level resolution. Maximus will assign an arbitrator and issue a written finding within 30 days of receiving a completed IDR application.

Two ways to start IDR: Online portal or phone
Phone: 1-888-866-6205
Online: Create an account on the Maximus portal and complete the dispute application
Documents often needed: copy of bill(s); claim form(s) if available; Explanation of Benefits (EOB) if available; relevant communications between patient, provider and/or health plan; proposed dollar amount you will accept
Maximus will assign an arbitrator and issue a written finding within 30 days of a completed application
Learn more on the Maine Bureau of Insurance website

Key Definitions

Surprise bill definition -- inv-04

Definition (Surprise bill)A bill for covered services (including emergency services) from an out-of-network provider that the member did not knowingly choose.

Common situationsMay occur during a service or procedure at a participating hospital or emergency facility, or during a service previously approved or authorized by Aetna.

Not a surprise bill when knowingly chosenIf a network provider was available but the member chose a non-network provider, the bill is not considered a surprise bill.

Covered emergency services cost sharing -- inv-05

Member cost sharing for surprise and emergency servicesMembers pay only their network deductible, copay, or coinsurance for surprise bills and covered emergency services.

Do not pay the full out-of-network billMembers should not pay the bill and should call the toll-free number on their member ID card to report the bill so Aetna can review and attempt to resolve it.

If Aetna pays more after negotiation or IDRIf Aetna pays additional amounts to resolve a claim, the member's cost share will not increase.