(e)__Inform the enrollee of the enrollee's rights to seek further review by the courts, or other process, of the external appeal determination.

This subsection may not be construed as removing or limiting any legal rights of enrollees and others under state or federal law, including the right to file judicial actions to enforce rights.

A decision under this subsection is not considered final agency action pursuant to Title 5, chapter 375, subchapter VII.

Sec. 17. 24-A MRSA §4305, sub-§1, as enacted by PL 1995, c. 673, Pt. C, §1 and affected by §2, is amended to read:

1. Internal quality assurance program. A health plan carrier that subjects plan benefits to review for medical necessity or appropriateness must have an ongoing quality assurance program for the health care services provided or reimbursed by the health plan carrier that meets the following requirements.

A.__The carrier has a separate identifiable unit with responsibility for administration of the program.

B.__The carrier has a written plan for the program that is updated annually and that specifies at least the following: the activities to be conducted; the organizational structure; the duties of the medical director; and criteria and procedures for the assessment of quality.

C.__The program provides for systematic review of the types of health services provided, the consistency of services provided with good medical practice and patient outcomes.

D. The program:

(1)__Uses criteria that are based on performance and patient outcomes when feasible and appropriate;

(2)__Includes criteria that are directed specifically at meeting the needs of at-risk populations and enrollees with chronic conditions or severe illnesses, including gender-specific criteria and pediatric- specific criteria when available and appropriate; and