Whom to contact:

North Carolina Department of Insurance, Healthcare Review Program

Who can appeal:

You or your authorized representative

What you can appeal:

External review is available when your health plan denies coverage for services or requested services on the grounds that they are not medically necessary.

When you can appeal:

You can file a request for external review within 60 days of receiving notice of your health plan’s final decision from the highest level of appeal offered, or for expedited external review, within 60 days of receiving either the initial denial or decision on appeal.

What to send:

1. Completed external review request form, unless expedited request (which can be made orally or in writing)
2. Copy of notice of final determination denying coverage from insurer
3. Signed medical authorization release form, and
4. Copy of your health insurance card.

What you must pay:

No charge

What will happen:

The Healthcare Review Program will:

1. Conduct a preliminary review of your request to determine eligibility for external review. Within 10 business days after requesting external review, you will receive notification whether the request is complete and whether it has been accepted for review. Your health plan and provider will be notified at the same time.
2. If accepted for review, your case will be assigned to an independent review organization (IRO).
3. For a standard review, you may provide written information to the IRO within 7 days after the date of notice of acceptance. That same information must be provided to your health plan by the same means as it was provided to the IRO.

The Independent Review Organization will:

1. Have a medical expert(s) review the case.
2. Make a determination in writing in which you, your provider, and insurer are notified of the decision.

When you will get a decision:

External review is performed on either a standard or expedited timetable, depending on which is requested and on whether medical circumstances meet the criteria for expedited review. A decision is issued by the IRO within 45 days of the Healthcare Review Program receiving the request for standard reviews.

In urgent situations:

An expedited external review of a noncertification decision (denial) may be available only when having first completed your health plan’s internal appeal process (even on an expedited basis) or receiving a standard external review through the Healthcare Review Program would put your life, health, or recovery in serious jeopardy. A decision is issued by the IRO within 4 days of the Healthcare Review Program receiving the request.