Instructions for Completing the Maine Tick Borne Disease Claim Form
Required by 24-A M.R.S.A. § 4302(5)
This form is to be completed for all claims made (dates of service) in the previous
calendar year for covered individuals in Maine relating to the following diseases and their
accompanying ICD-9 codes (ICD-10 codes in parentheses).
Lyme Disease (Borreliosis) ICD-9 code 088.81 (A69.2)
Babesiosis ICD-9 code 088.82 (B60.0)
Ehrlichiosis (Anaplasmosis) ICD-9 code 0.82.4 plus all subcategories: 082.40,
082.41, 082.49 (A79.8, A79.9)
Rocky Mountain Spotted Fever ICD-9 code 082.0 (A77.0)
Powassan Virus (tick-borne viral encephalitis) ICD-9 code 063.8 (A84.8)
To access your online form:
Go to the following website: https://gateway.maine.gov/Insurance/.
Enter your license number and access code, which were included in the e-mail
notification that you received from our office.
Then click on the Submit button. This brings you to the Forms Available screen
which shows you the forms that you need to complete.
Under Forms and Descriptions, click on the Tick Borne Disease Claim Form. This
brings you to the Form Status and Periods Available Screen. You will see three
categories: Submitted Forms (Those already completed and submitted to our
database), Forms Currently in Process (Forms that you have worked on and saved
but have not submitted to our database. These are not complete until you submit
them), and Forms Available for Completion (Forms that you have not yet worked
on. These are not complete until you enter the information and submit them). A
blue hyperlink will appear in only one of these three categories. Remember, you
are not finished until information has been entered and the form has been
submitted. Therefore, if there is a blue hyperlink listed under Forms Currently in
Process or Forms Available for Completion, then you must click on the link so
you can complete the form and submit it. Doing so will bring up the Tick Borne
Disease Claim Form. This online form is comprised of various sections described
Section: Company and Contact Information
This section contains the calendar year that the report covers and your company name,
license number and mailing address. You must select a contact person by clicking on the
drop down arrow beside Select a Contact.
If the name of the person completing this year’s report appears in the drop down
list, highlight that name and click on the Attach Contact button. Information such
as Title, Address, Phone, Fax and E-Mail appears. If the contact information for
that person is not correct, click on the Add/Update Contacts button. Next Click on
the Edit Contact button beside the Contact Person for whom you want to update
information. Make any necessary changes and click on the Save Contact button.
You will see a green message if the changes were successful. Then click on the
Return to Form button to continue working on the Tick Borne Disease Claim
If the name of the person completing this year’s report does not appear in the drop
down list, click on the Add/Update Contacts button. Under Contacts, click on the
New Contact button. The New Contact screen appears. Enter information about
the new contact and then click on the Save Contact button. When you are
finished, click on the Return to Form button. You may then select the contact
person by clicking on the drop down arrow beside Select a Contact and then click
the Attach Contact button. After attaching the contact to the report, you may
continue working on the Tick Borne Disease Claim Form.
Section: Number of Claims Submitted for All Tick Borne Diseases
Enter the number of claims submitted for the specified Tick Borne Diseases, along with
the number of those claims that were denied, those that were paid, and the total amount of
payments for those claims. Please include only claims that required treatment. Exclude
laboratory, imaging or other claims related to diagnosing tick borne diseases. The data
reported should be the number of claims, not the number of enrollees.
Section: Number of Claims Submitted for the Types of Treatment for
Provide information regarding treatment-for Lyme disease claims. Exclude things like
laboratory work and imaging. If an enrollee submitted a claim for an antibiotic on several
different occasions within the calendar year, combine the length of time the antibiotic
was taken for the purpose of determining if the treatment was for 8 weeks or less or for
over 8 weeks. Do this of each enrollee affected. Please list details about what the Other
Types of Treatments were in the blank box (comments section) at the bottom of the
online form. Other treatment may include non-antibiotic therapies administered for
treatment of Lyme disease-- including physical therapy, acupuncture, behavioral health,
osteopathic manipulation, or other prescription medications.
Note: It is possible for information about one enrollee to be entered in more than one
category. For example, an enrollee could have paid claims for some antibiotics for 8
weeks or less during the calendar year. That same enrollee could have a different
antibiotic for 8 weeks or less be denied and additionally have a prescription for more than
8 weeks be paid. Therefore, it may be acceptable to enter data for the same enrollee in
more than one place.
Section: Reasons for Denied Tick Borne Disease Claims
Include in your totals all of the denials related to any treatment for all of the tick-borne
diseases combined. Denials may fall into more than one category, please include all the
denial reasons as appropriate. For Other reasons, please list them in the blank box
(comments section) at the bottom of the online form.
Number of Appeals/Reconsiderations and External Reviews for All Tick
For Internal Appeals and Reconsiderations and for Independent External Reviews
(conducted by you and not by the Bureau of Insurance), enter how many of these were
Upheld, Overturned, and Other. For any listed as other, enter the details in the blank box
(comments section) at the bottom of the online form.
Totals fields are calculated by the system. In the Appeals/Reconsiderations section, you
enter figures for upheld, overturned and other and then you must click on the Calculate
button. It will put the sums into the totals field. You cannot enter data directly into this
If you have begun your report but want to finish it at a later time, you may click on the
Save button and all work that you have done on the form thus far will be available when
you return to complete the form. Remember, you are not finished until you submit the
information to our database.
When you click on the Submit button, your information will be submitted to the Bureau
of Insurance and will no longer be available for editing. You will receive a confirmation
email with a PDF file containing your data report.
When you have finished the report, you may click on the Print PDF button to generate a
PDF document of the completed report for your records.
If you have specific questions about how to report Tick Borne Disease claims or their
treatments, contact Glenn Griswold at Glenn.J.Griswold@maine.gov or (207)-624-8453.
If you have technical questions related to completing this report or need to have your
report reopened to correct information after it has been submitted, please contact Brad
Brown at Bradford.L.Brown@maine.gov or (207)-624-8478.