NORTH CAROLINA

If your insurer denies your claim because it determines that the services or treatment you requested were not medically necessary, you can request an informal reconsideration of the denial.^[1] The informal reconsideration process provides an opportunity for your health care provider and the insurer to discuss your medical condition in detail and, if possible, resolve the matter without a formal appeal. You are not required to request an informal reconsideration; however, doing so may resolve your matter in less time and with less effort than is required for a formal first level appeal. You or your health care provider can call your insurer to determine if it offers this option.

If your insurer denies your claim because it determines that the service or treatment you requested was not medically necessary, you have the right to a formal first level appeal.^[2] This means you can ask your insurer to conduct a full and fair review of its decision.

To request a formal first level appeal, you should do the following:

• Review the determination letter. Your insurer should have sent you a determination letter telling you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
• Collect information. In addition to the determination letter, collect all documents that your insurer sent you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
• Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
• Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
• Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider, a clear statement from you explaining why you believe the insurer’s decision was wrong, and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
• Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

You can file a first level grievance with your health insurer if your insurer denies your requested service or treatment for any reason other than medical necessity. Reasons may include availability, delivery, or quality of health care services; payment of claims; or any disputes arising from the contractual relationship between you and the health insurer.^[3]

To file a first level grievance, you or your health care provider should submit a complaint in writing to your health insurer.^[4] Be sure to follow your insurer’s instructions for filing the grievance closely.

If your insurer denies your claim after a first level appeal or first level grievance, you may (but are not required to) file a second level grievance with your insurer.^[5] Your health care provider can submit the request for you.^[6] Instructions for filing a second level grievance should have been included in the health insurer’s denial letter from the first level appeal or grievance.^[7]

During a second level grievance, the health insurer is required to form a review panel and conduct a hearing, which you can attend either in-person or by phone.^[8]The hearing must be held within 45 days from when your insurer receives your second level grievance request.^[9]

If waiting 30 days for your requested treatment or service would seriously jeopardize your life or health, you or your health care provider can request an expedited first level appeal or grievance.^[10] Instructions on how to request an expedited appeal or grievance should have been included in your health insurer’s denial of benefits letter.^[11]

You can also request an expedited second level grievance if waiting an additional seven days for your requested treatment or services would seriously jeopardize your life or health. You can make this request even if you did not request an expedited first level appeal or grievance.^[12]

The first level appeal or grievance should take a maximum of 30 days.^[13] If you request a second level grievance, you should receive a decision within seven days following the hearing.^[14] If you request an expedited appeal or grievance, you should receive a decision within four days of your insurer receiving your request.^[15]

During an external review, an independent third party reviews your insurer’s decision.^[16] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under North Carolina law, you are entitled to request an external review if your insurer denies your appeal on the basis that the services are not medically necessary, are experimental, or are cosmetic.^[17]

You can also request an expedited external review in urgent situations at the same time you file a request for an expedited appeal.^[18] Your situation is urgent if waiting would jeopardize your life or ability to function.

You should submit your request for an external review to the North Carolina Department of Insurance, Health Insurance Smart NC (“Smart NC”).^[19] You must file your request within 120 days from the date that your insurer sent you its final decision.^[20]

Information. You can find a copy of the request form here. You should include the following information with your request:

• The name, address, telephone number, email address, and date of birth of the patient;
• The name, address, telephone number, email address, and relationship to patient of the person filing the request (if different from the patient);
• The name, practice type, address, and telephone number of the health care provider;
• Information regarding the denied service;
• The name of the insurance company;
• The name of the insured individual;
• The member identification number, group number, and name of employer, if applicable; and
• The name and address of the treating physician and the telephone number and address of the health care practice.^[21]

Requesting an expedited review. When you fill out the external review request form, be sure to indicate on page 2 of the form that you are requesting an expedited review.^[22] You should include medical records and other supporting information from your health care provider explaining why your case should be expedited.^[23]

Supporting documents. You should also include the following documentation:

• A signed medical record release form (included in the external review request packet);
• A copy of your insurance card;
• A copy of the final denial letter from your health insurer;
• A description of the disagreement; and
• Any additional or new information and documentation not included with your request for an internal appeal or grievance.^[24]

Submitting an external review. If you are requesting a standard external review, you can submit your request online here, fax it to (919) 807-6865, or mail it to the following address:

NC Department of Insurance
1201 Mail Service Center
Raleigh, NC 27699-1201^[25]

The review process should take no more than 45 days from the date the review organization receives your request.^[26] If you requested an expedited external review, the process should take no longer than three business days after receiving your request.^[27]

If you are a North Carolina resident and you believe your insurer did something illegal or unethical, you can file a complaint with the North Carolina Department of Insurance, Health Insurance Smart NC Division (“Smart NC”).

Complaint information. Your complaint should include the following information:

• The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
• The Complainant’s relationship to the insured individual;
• The name of the insured individual, if different than the Complainant;
• The name of insurance company;
• The policy or group number, claim or certificate number, and date of loss;
• The name of the insurance agent and adjuster in your case; and
• The details of the complaint.

Supporting documents. You should submit the following supporting documents with your complaint:

• A copy of your insurance card;
• Copies of determination letters from your insurer;
• Copies of any determinations made by internal and external reviewers;
• Any materials submitted with prior appeals and complaints;
• Supporting documentation from your health care provider;
• A copy of your insurance policy; and
• All responses from your insurer.^[28]

How to submit. The complaint and supporting documents may be submitted online here or mailed to the following address:

North Carolina Department of Insurance
Health Insurance Smart NC
1201 Mail Service Center
Raleigh, NC 27669-1201^[29]

Once your complaint is received, Smart NC will forward a copy of the complaint to your health insurer and require it to respond.^[30] Smart NC will review your insurer’s response to determine whether its actions comply with all applicable laws, regulations, and policies. If the insurer has violated a law, regulation, or policy, Smart NC will require the company to take corrective action.^[31]

You can contact the North Carolina Department of Insurance at (855) 408-1212. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.