An Act to Create an Advocacy and Complaint Process for Health Care Providers Within the Bureau of Insurance
Maine Legislature, Session 131, LD 1498
Committee: Health Coverage, Insurance and Financial Services
Sponsors: PERRY, O'NEIL, LAWRENCE, DANA, GRAMLICH, MATHIESON, STOVER, CURRY
Amends: 24-A MRSA §4323

Legislative Document
No. 1498
H.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.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  24-A MRSA c. 56-A, sub-c. 2, headnote is amended to read:
SUBCHAPTER 2
CONSUMER HEALTH CARE DIVISION AND PROVIDER ASSISTANCE 
DIVISIONS
Sec. 2.  24-A MRSA §4323 is enacted to read:
§4323.  Health Care Provider Assistance Division
1.  Division established.  The Health Care Provider Assistance Division, referred to in 
this section as "the division," is established within the bureau.  The division shall work in 
coordination with other bureau sections and staff to accomplish the duties set forth in 
subsection 4.
2.  Director.  The Director of the Health Care Provider Assistance Division, referred 
to in this section as "the director," is the head of the division.  The director is appointed by 
the superintendent and is subject to the approval of the Commissioner of Professional and 
Financial Regulation.  The director is subject to the Civil Service Law.
3.  Staff.  The superintendent may hire or assign personnel as determined necessary to 
perform the duties of the division subject to the approval of the Commissioner of 
Professional and Financial Regulation and subject to the Civil Service Law.  The personnel 
are supervised by the director in consultation with the superintendent. The qualifications 
of those personnel must reflect the needs and responsibilities relating to the division's duties 
under this subchapter.
4.  Duties.  The duties of the division include:
A.  Providing access to the division through a toll-free number;
B.  Providing information to providers regarding health plan coverage;
C.  Assisting providers in navigating the health insurance industry;
D.  Assisting providers with concerns specific to individual patients, such as denied 
claims and prior authorization requests;
E. Addressing provider concerns on issues that may have a market-wide impact, such 
as unnecessary credentialing delays and misapplication of accepted medical standards;
F. Assisting providers with complaints relating to licensees under the bureau that may 
have violated a statute or rule;
G. Collecting and disseminating information regarding the activities of the division;
H. Submitting an annual report by January 1st of each year to the Commissioner of 
Professional and Financial Regulation and the joint standing committee of the 
Legislature having jurisdiction over insurance matters describing the activities carried 
out by the division in the year for which the report is prepared, analyzing the data 
available to the division and evaluating the problems experienced by providers; and
I.  Performing other duties as the superintendent may prescribe.
5.  Complaint process; investigations.  The following procedures apply to a complaint 
submitted under subsection 4, paragraph F.
A. A provider requesting assistance or filing a complaint shall complete a grievance 
form as prescribed by the division.
B. For a complaint or requests for assistance with concerns specific to individual 
patients, the provider must submit a release of information form.
C. Upon receipt of the grievance form under paragraph A, the division shall investigate 
the matter.
D. For complaints relating to individual patients that include a release of information 
form, the division shall provide the provider a response that may include documents 
relating to a patient's claim.
E. For complaints relating to individual patients that do not include a release of 
information form, the division shall provide the provider a response limited to a 
summary of the outcome of the investigation.
F. For complaints concerning issues that relate to violations of statutes or rules, the 
division shall provide the provider a response that summarizes the division's findings.
G. If the complaint concerns issues that may have a market-wide impact, the division 
shall refer the matters to the appropriate unit within the bureau and notify the provider 
that the provider will be contacted further only if the unit requires additional 
information.
H. An individual or entity that transacts insurance in this State or is otherwise subject 
to the authority of the bureau shall, upon request of the division, provide the division 
with all documents and information relevant to an investigation under this subsection 
within 10 business days or any additional time as approved by the division for complex 
matters.
I. The division may establish other procedures relating to the investigation of 
complaints under this subsection.
6.  Disclosure of documents and information.  Except as provided in this subsection, 
documents and information from an insurer or a national association of insurance 
commissioners, law enforcement agency or regulatory agency is confidential, is not subject 
to a subpoena, is not subject to discovery or admission into evidence in a private civil action 
and may not be the subject of testimony of the bureau.  The bureau may:
A. Use documents and information obtained through an investigation under this section 
as part of a regulatory or legal action brought as part of the duties of the bureau;
B. Share documents and information with other state, federal and international 
regulatory agencies, including a national association of insurance commissioners, an 
international association of insurance supervisors or a bank for international 
settlements as long as the recipient agrees to maintain the confidentiality of the 
documents and information;
C. Provide to a provider who made a complaint against an insurer a copy of the 
insurance company's letter to the division in response to the complaint as long as that 
information does not interfere with a civil, criminal or administrative enforcement 
proceeding; or
D. Disclose to the public the number of and nature of complaints and requests filed 
with the division under this section.
7. Rules.  The bureau may adopt rules to implement this section.  Rules adopted 
pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, 
subchapter 2-A.
SUMMARY
This bill establishes the Health Care Provider Assistance Division within the 
Department of Professional and Financial Regulation, Bureau of Insurance to assist health 
care providers in obtaining information about health insurance plans, assist health care 
providers in navigating the health insurance industry, assist health care providers with 
concerns specific to coverage for individual patients and issues that may have market-wide 
impact and provide a system for health care providers to submit complaints about violations 
of statutes or rules.