North Carolina Health Insurance Appeals and Grievances

What is an internal appeal?

North Carolina uses two related processes:

• Appeal of a noncertification (utilization review denial) under G.S. 58-50-61
• Grievance (broader complaints about decisions, payment, or quality) under G.S. 58-50-62

A noncertification appeal that is upheld is reviewed as a second-level grievance. Pure benefit exclusions clearly stated in your certificate may not go through grievance procedures.

This is different from external reviewthrough NCDOI's Smart NC program after internal processes are complete.

General walkthrough: Appeals roadmap.

North Carolina appeal timelines

Noncertification appeals (G.S. 58-50-61)

• Standard appeal: written decision within 30 days after the insurer receives the appeal; coordinator contact within 3 business days
• Expedited appeal: written decision within 4 days when medically justified
• Optional informal reconsideration with your provider first—you are not required to use it

Grievances (G.S. 58-50-62)

• First-level grievance: written decision within 30 days
• Second-level grievance: panel meeting within 45 days of request; insurer decision within 7 business days after the meeting
• Expedited second-level: review and decision within 4 days after all necessary information
• You may attend the second-level panel, submit evidence, and bring a representative (including an attorney)

Before external review

For medical-necessity noncertifications, you generally must complete the insurer's appeal and second-level grievance (when upheld) before requesting external review under G.S. 58-50-80.

How to file

1. Read the denial—confirm whether it is a noncertification, grievance, or pure benefit exclusion.
2. Follow the plan's written instructions and keep proof of the date filed.
3. Request expedited review if delay would cause serious harm.
4. Request second-level grievance if your noncertification appeal is denied.
5. Ask for clinical review criteria used in the denial (G.S. 58-50-61(h)).

Carrier links: North Carolina prior auth & internal appeals links.

Evidence that helps

• Treating clinician letter on medical necessity
• Clinical review criteria the plan relied on
• Peer-reviewed literature for experimental/investigational disputes

See Building a strong appeal packet.

Medicaid appeals

Medicaid managed care (Healthy Opportunities, Standard Plans, Tailored Plans):

• MCE level appeal: within 60 days of the adverse benefit determination notice (G.S. 108D-13)
• MCE must issue a notice of resolution within about 30 days (extensions possible with notice)
• Contested case hearing (fair hearing): file with the Office of Administrative Hearings within 120 days of the notice of resolution (G.S. 108D-15); OAH must schedule within 55 days of receipt

Some Medicaid medical-necessity denials may also qualify for commercial-style DFS external review—read your notice carefully.

More: Medicaid managed care appeals.

After internal appeal

If you receive a final denial upholding a noncertification, request external review from NCDOI within 120 days (Smart NC — external review).

Next: North Carolina external review.