North Carolina health insurance appeal rights

Denied in North Carolina? You have a two-step path: an internal appeal to your plan, then a free external review through the state’s Smart NC program. Here’s how it works — and why 120 days is the deadline to watch.

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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

Start by appealing to your plan in writing, with your denial notice and the records that support your case. Federal rules generally give you at least 180 days from the denial to file the internal appeal — check the deadline on your own notice. If your situation is urgent, you can ask for an expedited review, and in some cases request an expedited external review at the same time.

Step 2 — request an external review

Once the plan upholds its denial, submit a written external-review request to Smart NC. The review is free. Within 10 business days Smart NC tells you whether your request is complete and accepted, then assigns the IRO. A standard external review is decided within 45 days of Smart NC receiving your request; an expedited review for urgent cases is decided within about three to four business days. The IRO’s decision is binding on you and your plan — if it overturns the denial, the plan must provide coverage or payment (within three days for a standard review, one day for an expedited one).

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.