Maine surprise billing and emergency services IDR process
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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.
No material clinical or coverage changes in this revision.
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:
Not considered a surprise bill when
- A network provider was available but the member chose to get services from a non-network provider.
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.
IDR Eligibility Threshold
How Providers Initiate Disputes
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
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.