Sec. 1. 24-A MRSA §4303, sub-§5 is enacted to read:

5.__Independent external review of coverage decisions.__An enrollee who has exhausted all internal grievance and appeals procedures provided by a carrier offering a health plan in this State has the right to an independent external review of a health plan's decision to deny, reduce or terminate health care coverage or to deny payment for health care services.__The independent external review is subject to the following requirements.

A.__The decision being reviewed must be based on one of the following reasons:

(1)__The health care service is a covered benefit that the carrier has determined is not medically necessary in the case of the enrollee;

(2)__A limitation placed on the selection of a health care provider is claimed by the enrollee to be inconsistent with limits imposed by the health plan or by applicable laws and rules;

(3)__The health care treatment has been determined to be experimental or investigational; or

(4)__The health care service involves a medically based decision that a condition is preexisting.

B.__The independent external review must be requested in writing by the affected enrollee and a filing fee of not more than $25, reflecting the administrative costs of processing a request for review under this subsection, must be paid by the enrollee to the bureau.__The filing fee may be waived or reduced based on a determination by the superintendent that the financial circumstances of the enrollee warrant a waiver or reduction.

C.__The enrollee may use outside assistance during the review process and submit evidence relating to the health care service.

D.__The independent external review must be conducted by an independent review organization pursuant to a contract with the bureau.__The reviewers must be health care providers credentialed with respect to the health care service under review and have no conflict of interest relating to the performance of their duties under this subsection.