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North Carolina Health Insurance Appeals and Grievances

Appeals And Grievances And Requests For External Review

Appeals and Grievances

If you are dissatisfied with a claims decision made by your health insurance company, you may have the right to challenge that decision through an appeal and/or grievance process. A guide describing the appeal and grievance provisions in North Carolina law is available through the Department of Insurance by calling 1-800-546-5664 or visiting www.ncdoi.com. Laws regulating appeals and grievances apply to all types of full service health plans, including traditional indemnity, HMO and PPO plans. Patients with certain health conditions may be eligible for an expedited (quicker) appeal process. Details concerning your plan's appeal and grievance procedures should be included in your employee handbook, certificate of coverage and insurance policy.

External Review af Health Plan Denials

The North Carolina Department of Insurance Health Care Review Program (HCR) administers a free service called External Review, which provides another option for resolving certain coverage disputes between you and your insurance company. In North Carolina, external review is available when an insurance company denies coverage on the grounds that the requested service is not medically necessary (this is called a "non-certification" decision), or that the requested service is cosmetic or experimental for your specific medical condition.

For your request to be accepted for external review, you must meet the Program's eligibility requirements. A request is made directly to the HCR Program and each case is reviewed for completeness and eligibility. If accepted for external review, the case is assigned to an independent review organization (IRO) for a clinical review and final decision. Additional information about External Review can be found on the Department's Web site at www.ncdoi.com, or by calling the HCR Program at 1-877-885-0231.