New to helping someone in North Carolina?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan. Use the name and phone number on the card when you call or file paperwork.
- Denial letter or explanation of benefits (EOB) — the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline.
- Summary of Benefits and Coverage (SBC) — helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (Marketplace, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter.
North Carolina law gives you utilization review appeals and grievance procedures with the insurer first, then a right to external review through Health Insurance Smart NC at the Department of Insurance.
For steps that work in every state, read these general guides first, then return here for North Carolina rules:
What is different in North Carolina?
- HealthCare.gov: North Carolina uses the federal Marketplace at HealthCare.gov. Major 2026 carriers include Blue Cross NC, Ambetter, AmeriHealth Caritas, Cigna, Oscar, and UnitedHealthcare (availability varies by county).
- Prior authorization (G.S. 58-50-61): Utilization review — 3 business days for prospective/concurrent determinations after necessary information; 30 days retrospective; denials reviewed by a North Carolina-licensed physician; limited retroactive denial of properly authorized care (§§ 3228, 4905).
- Internal appeals: Noncertification appeal within 30 days standard / 4 days expedited; many cases also require second-level grievance (G.S. 58-50-62).
- External review: File with NCDOI within 120 days (G.S. 58-50-80); IRO decision within 45 days standard / 3 days expedited; binding on plan.
- Medicaid managed care: MCE appeal within 60 days, then contested case hearing with OAH within 120 days of plan resolution (G.S. 108D-15)—separate from commercial Smart NC review.
Who is in charge of your plan?
- NCDOI — Health Insurance Smart NC: External review, consumer help — ncdoi.gov. 855-408-1212 · Consumer line: 800-546-5664.
- U.S. Department of Labor: Many self-funded employer plans.
- NC Office of Administrative Hearings: Medicaid managed care contested case hearings.
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.