Written by a parent, not a doctor. Nothing here is medical advice.

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Maine program

Deadlines for the plan’s treatment decision

Maine-regulated plans must meet deadlines when they review certain treatment and drug requests.

What it is

Maine-regulated plans must meet deadlines when they review certain treatment and drug requests.

Waiting for a plan’s answer can hold up treatment. Maine sets decision clocks and consequences for missing them. Your clinician’s complete submission and your plan’s regulator determine which protection applies.

Eligibility rules
  • Maine-regulated plans, including Marketplace plans, are covered. Government and teacher plans need a plan-specific review.
What you get
  • A standard nonemergency treatment decision within 72 hours or two business days, whichever is less.
  • Approval when the law’s applicable treatment-request deadline is missed; billing and appeal delays use different rules.
  • An urgent drug step-rule exception decision within 24 hours in qualifying circumstances.
What the help includes
  • A contraindication, likely adverse reaction or harm can support an exception to step therapy.
  • The prescribed drug remains covered while the override request or appeal is pending. A missed applicable override deadline grants the exception.
  • Continuity protections provide at least 60 days of continued treatment after a clinician leaves the network, when the rule applies.
If you decide to apply
  1. Ask the prescribing clinician when the plan received the complete request.
  2. Have the request, receipt confirmation and any plan response ready when discussing the deadline with the plan.

Your prescribing clinician and health plan; Maine Bureau of Insurance · Official page ↗

After you ask
  • The prescriber documents the request and can explain exigent circumstances for the 24-hour drug exception.
  • Section 4304 has separate timing rules after requested information arrives and when outside consultation is needed. The team records these dates separately from initial receipt. Deemed approval applies to the specific grant-or-deny requirement, not every uncovered service or late appeal.
Good to know

Your prescribing team can confirm which request clock applies. Private employer plans that pay their own claims usually use federal rules.

Other details
  • A request to skip a "try this drug first" step, or to cover a drug not on the plan’s list, must be answered within 24 hours when urgent, and the prescribed drug stays covered while the plan decides. If the plan misses the deadline, the exception is granted.
  • The Bureau of Insurance and your plan can confirm the urgent initial-review rule and whether any prescriber exemption from routine approval requests applies. The plan can also explain how manufacturer assistance counts toward your deductible and spending limit.
Official sources
Ask your social worker

“Which decision deadline applies to my child’s treatment request, and what happens if the plan misses it? Could you help us weigh and request the right review?”

Why I’m asking: I want to understand whether a delayed decision has a remedy that helps treatment proceed.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Get the submission date and time, and hold the plan to the clock in writing.

Your social worker

The prescriber sends the complete request and records when.

The care team

The prescriber can state that circumstances are exigent, which shortens the drug clock to 24 hours.

Who decides
Your health plan, inside a deadline the law sets.
Ask the care team
“When exactly did the plan get the complete request? Maine gives them 72 hours or two business days, and a missed deadline means it is granted.”

How to apply

First step: Ask the prescriber for the date and time the complete request reached the plan.

  1. Ask the prescriber for the date and time the complete request went to the plan.
  2. If the deadline passes, write to the plan saying the request is granted by law.
  3. Complain to the Bureau of Insurance on 207-624-8459 if it argues.

Official application / program page ↗

Where it starts: Ask the prescriber to record when the complete request went in, then hold the plan to the clock.

What to gather

  • The submission date and time
  • The plan's reference number
  • The prescriber's note on urgency

How long: 72 hours or two business days, whichever is less; 24 hours for an exigent drug request.

What a yes looks like

An authorization number, or a written acceptance that the deadline passed.

What a no looks like, and the next move

Ask for the exact ground, then use the free external review and tell the Bureau of Insurance.

Watch out

  • Write down when the plan received the complete request. That is when the clock starts.
  • While a step-therapy override is pending, the prescribed drug stays covered.
  • A private employer's self-funded plan is outside these clocks; a government or teacher plan needs checking.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 11, 2026.

What it is worth

Standard nonemergency requests generally use the shorter of 72 hours or two business days, subject to Section 4304 request rules. Deemed approval applies to its specified deadline.

  • $72 — Hours for a standard non-emergency decision, or two business days if sooner
  • $24 — Hours for an exigent step-therapy override
  • $60 — Minimum days of continued care after the doctor leaves the network

Legal protection: A missed prior-authorization deadline means the request is granted · A missed step-therapy deadline means the exception is granted · The prescribed drug stays covered while an override request or appeal is pending · Contraindication, or a likely adverse reaction or harm, is a ground for a step-therapy override · At least 60 days of continued treatment after a provider leaves the network

What it costs the family: None.

The eligibility facts, as published

Plan type
a Maine-regulated health plan, including Marketplace plans; a private employer's self-funded plan is outside
Note
The plan and Bureau of Insurance confirm the current general urgent-initial rule, any prescriber exemption and the specific request clock.

Expect friction on: Someone has to notice the deadline passing

The trap: Write down the date and time the plan received the complete request. That is when the clock starts, and it is what you point at if the deadline passes. Ask the prescriber to note when they sent it.

Where I read this

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