What is external review?
External review is an independent review of certain final denials. The North Carolina Department of Insurance (NCDOI) administers the program through Health Insurance Smart NC, which assigns a certified independent review organization (IRO)to review your records and decide whether the plan's denial should stand.
The IRO is not your insurance company. For eligible cases, the IRO decision is binding on you and your health plan.
General overview: Appeals roadmap. Complete North Carolina internal appeals first unless an urgent exception applies.
Who can use North Carolina review?
External review generally applies when:
- You have an NCDOI-regulated health benefit plan (most fully insured commercial and Marketplace plans)
- The dispute involves a medical necessity noncertification or similar adverse benefit determination for a covered service
- You had coverage when the denial was issued and exhausted internal appeal levels
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review may still apply)
- Original Medicare and Medicare Advantage (federal Medicare appeals)
- Pure benefit exclusions that are not medical-necessity determinations
- Dental-only, vision-only, or other excluded plan types listed in G.S. 58-50-61
Deadlines & exhaustion
120-day filing window
File a request for external review with the Commissioner within 120 daysafter you receive notice of the insurer's final appeal decision (G.S. 58-50-80(a)). For expedited external review, the clock may start from the initial denial or appeal decision—follow your notice.
Providers appealing on their own behalf
Health care providers filing external review for themselves(not as the patient's designee) generally must file within 60 days (DFS application instructions).
Exhaust internal appeal first
Complete the insurer's noncertification appeal and second-level grievance when required. Your final denial should advise you of the right to external review (G.S. 58-50-62(h)(7)).
How to file
- Complete internal appeal and second-level grievance when required.
- Gather the denial letter, appeal decisions, policy, and medical records.
- Complete the External Review Request Form from NCDOI — request external review.
- Submit to Health Insurance Smart NC by mail, fax, or as instructed on the form.
- If Smart NC accepts your case, you may submit additional information to the IRO within 7 days ( G.S. 58-50-80).
Mail: Superintendent of Insurance, Attn: Smart NC, 1201 Mail Service Center, Raleigh, NC 27699-1201 · Phone: 855-408-1212
Links hub: North Carolina external appeals links.
How long it takes
- Standard review: IRO decision within 45 days of a complete, accepted request (Smart NC materials)
- Expedited review: generally within 3 days (or 1 day in some expedited cases per NCDOI summaries)
- Smart NC screens for conflicts of interest before assigning the IRO
Is the decision binding?
For eligible disputes, the IRO decision is binding on you and your health plan (NCDOI). If the IRO overturns the denial, the plan must provide coverage or payment consistent with the decision, generally within 3 days for standard reviews.
You generally cannot request a second external review of the same denial (G.S. 58-50-80).
Medicaid & Medicare
Medicaid managed care: MCE appeal, then OAH contested case hearing (G.S. 108D-15)—not the same as commercial Smart NC review, though some Medicaid denials may also qualify for DFS external review.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS.
More: Medicaid managed care · Medicare appeals.