How to appeal a health insurance denial in North Carolina
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. North Carolina lets you ask an independent reviewer to decide, through North Carolina Department of Insurance (Health Insurance Smart NC). The deadline to ask: within 120 days of receiving your insurer's final decision on appeal (for expedited review, within 120 days of the initial denial or the appeal decision).
Does this apply to you? State external review covers plans regulated by North Carolina: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in North Carolina
Within 120 days of receiving your insurer's final decision on appeal (for expedited review, within 120 days of the initial denial or the appeal decision)
Smart NC decides within 3 business days whether your request qualifies, and the reviewer's decision comes within 4 business days of the request. Use the print, mail or fax form with Attachment A: Physician Certification, because the online form handles standard requests only. You must also have requested an expedited appeal with your insurer.
Free
State-regulated plans (insurance bought in North Carolina or through an employer that buys insurance). Self-funded employer plans use the federal process.
You file with Smart NC (online form for standard review, or the paper form by mail or fax to 919-807-6865). Only medical-necessity denials qualify. If Smart NC says your request is incomplete, you must finish it within 150 days of the insurer's final decision. Unusually, the self-funded NC State Health Plan is also covered, but Medicaid, Medicare and other self-funded employer plans are not.
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in North Carolina?
Within 120 days of receiving your insurer's final decision on appeal (for expedited review, within 120 days of the initial denial or the appeal decision)
Can I get a fast external review in North Carolina?
Smart NC decides within 3 business days whether your request qualifies, and the reviewer's decision comes within 4 business days of the request. Use the print, mail or fax form with Attachment A: Physician Certification, because the online form handles standard requests only. You must also have requested an expedited appeal with your insurer.
Does external review cost anything in North Carolina?
Free
Do North Carolina’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- NCDOI: Request an External Review
Your request was submitted within 120 days of receiving your insurer's final decision on appeal
- NCDOI: Request an External Review (expedited)
You will receive verbal or written notification of the IRO's decision within four business days of making your request to Smart NC.
- NCDOI: Request an External Review (cost)
External Review is a free service to help you if your insurance company has denied coverage of a medically necessary treatment.
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.