North Carolina health insurance appeal rights

Deadline details depend on the applicable plan and actual notice. Check the source-verified appeal directory and official instructions.

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How appeals work in North Carolina

North Carolina gives you a two-step path after a denial. First you appeal to your health plan (the internal appeal). If the plan still says no, you can request a free external review through Smart NC, the consumer program at the North Carolina Department of Insurance. Smart NC assigns an independent review organization (IRO) — a reviewer outside your insurer — and the plan is required to abide by the outcome.

External review generally applies when a plan denies care as not medically necessary. It covers state-regulated plans and the North Carolina State Health Plan. (Self-funded employer plans governed by federal ERISA rules follow the federal external review process instead, and Medicare and Medicaid have their own systems — your denial letter will say which applies.)

Step 1 — your internal appeal

Deadline details depend on the applicable plan and actual notice. Check the source-verified appeal directory and official instructions.

Step 2 — request an external review

Deadline details depend on the applicable plan and actual notice. Check the source-verified appeal directory and official instructions.

Where to file and get help

• Request a review — use the Smart NC external review request form (online, or print to mail/fax).
• Smart NC consumer line — 1-855-408-1212 (toll free).
• By mail — NC Department of Insurance, 1201 Mail Service Center, Raleigh, NC 27699-1201 (fax 919-807-6865).

Putting it together

Read the denial, file your internal appeal, then request the free Smart NC external review — and mind the 120-day deadline. Our step-by-step guide covers each stage, external review explains independent review generally, and our appeal-deadline guide helps you track your dates. In another state? See Georgia or Florida appeal rights.