North Carolina: Start Here
Beginner guide for North Carolina—HealthCare.gov, Smart NC external review, G.S. 58-50-61 PA & grievance deadlines.
Read guideState playbook
North Carolina
State insurers, legislation, and appeal resources for patients and advocates in North Carolina.
4 guides
North Carolina Prior Authorization Law
G.S. 58-50-61—3-day UR/PA, 30-day retrospective, NC-licensed physician review, noncertification appeals.
Read guideNorth Carolina Health Insurance Appeals and Grievances
30-day noncertification appeal, second-level grievance, 4-day expedited, path to Smart NC external review.
Read guideNorth Carolina External Review (Smart NC)
Binding on plan—120-day filing with NCDOI, 45-day IRO decision, 3-day expedited.
Read guidePrior auth & internal appeals
Match the plan on the member ID card. Use the denial letter for where to file appeals.
- Blue Cross and Blue Shield of North Carolina
- Ambetter of North Carolina
- AmeriHealth Caritas North Carolina
- Cigna Healthcare of North Carolina
- Oscar Health
- UnitedHealthcare of North Carolina
- HealthCare.gov (North Carolina Marketplace)
- NC Medicaid managed care
External appeals
After internal appeal, for eligible North Carolina fully insured plans only.
- NCDOI — Health Insurance Smart NC
- Medicaid — contested case hearing