What is prior authorization?
In North Carolina, prior authorization is part of utilization review—the insurer's process to decide whether care is medically necessary before or after it is provided. A denial is often called a noncertification.
Overview: Prior authorizations. North Carolina-only details below.
Confirm plan type: North Carolina: Start Here.
North Carolina PA rules
North Carolina's utilization review statute is G.S. 58-50-61 (Chapter 58, Article 50). It applies to most fully insured health benefit plans regulated by NCDOI—not Medicare, Medicaid fee-for-service, or typical self-funded ERISA plans.
Standard UR deadlines (G.S. 58-50-61)
- Prospective and concurrent review (including PA): decision communicated to the provider within 3 business days after the insurer receives all necessary information
- Retrospective review: determination within 30 days after necessary information; written noncertification notice to member and provider within 5 business days
- Insurers may only request information clinically necessary to decide the request
- Noncertifications must be evaluated by a physician licensed in North Carolina
Appeals of noncertifications (same statute)
- Standard appeal: written decision within 30 days of the appeal request
- Expedited appeal: within 4 days when delay would seriously jeopardize life, health, or ability to regain maximum function
- Reviewed by a different NC-licensed physician who was not involved in the initial noncertification
Other protections
- Emergency services: prudent layperson standard under G.S. 58-3-190
- HMO continuity of care: up to 90 days with a departing provider when you notify the plan within 45 days (G.S. 58-67-88)
- Carriers generally cannot retroactively deny properly pre-authorized services except in limited circumstances (ineligibility, untimely claim, benefit exhaustion, fraud, or materially inaccurate information—§§ 3228, 4905)
The General Assembly has considered additional PA reforms (for example, House Bill 434) with shorter deadlines and deemed-approval rules—check current NCDOI guidance if your denial letter cites newer requirements.
Where to look up PA rules
Your certificate of coverage and member handbook must describe utilization review and appeal procedures (G.S. 58-50-61(m)). Use your denial letter first, then your plan's member or provider portal.
Carrier links: North Carolina prior auth & internal appeals links.
Medicaid
North Carolina Medicaid eliminated prior authorization for many procedure codes effective January 1, 2025, but managed care entities still use utilization management for other services. Denials follow MCE appeal and fair hearing paths—see North Carolina internal appeals.
If PA is denied
Appeal the noncertification using the insurer's written procedures, then pursue second-level grievance if required (G.S. 58-50-62).
Urgent care
Request an expedited appeal when a standard timeline would seriously jeopardize life, health, or maximum function—the insurer must decide within 4 days (G.S. 58-50-61(l)). During concurrent care, coverage continues until you are notified of a noncertification.
After internal levels are exhausted, expedited external review may be available within 3 days through Smart NC.