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External Review

Model EOC Language (Revised 8/24/11)

North Carolina law provides for review of noncertification decisions by an external, Independent Review Organization (IRO). The North Carolina Department of Insurance (NCDOI) administers this service at no charge to you, arranging for an IRO to review your case once the NCDOI establishes that your request is complete and eligible for review. You or someone you have authorized to represent you may request an external review. [Healthplan] will notify you in writing of your right to request an external review each time you:

  • receive a noncertification decision, or
  • receive an appeal decision upholding a noncertification decision[, or
  • receive a second-level grievance review decision upholding the original noncertification].

In order for your request to be eligible for external review, the NCDOI must determine the following:

  • that your request is about a medical necessity determination that resulted in a noncertification decision;
  • that you had coverage with [Healthplan] in effect when the noncertification decision was issued;
  • that the service for which the noncertification was issued appears to be a covered service under your policy; and
  • that you have exhausted [Healthplan's] internal review process as described below.

External review is performed on a standard and expedited timetable, depending on which is requested and on whether medical circumstances meet the criteria for expedited review.

For a standard external review, you will be considered to have exhausted the internal review process if you have:

For companies that utilize just one level of internal review:

  • completed [Healthplan]'s appeal process and received a written determination on the appeal from [Healthplan], or
  • filed an appeal and except to the extent that you have requested or agreed to a delay, have not received [Healthplan]'s written decision on appeal within 60 days of the date you can demonstrate that you submitted the request, or
  • received notification that [Healthplan] has agreed to waive the requirement to exhaust the internal appeal process.

For companies that utilize two levels of internal review:

  • completed [Healthplan]'s appeal and second level grievance review and received a written second level determination from [Healthplan], or
  • filed a second level grievance and except to the extent that you have requested or agreed to a delay, have not received [Healthplan]'s written decision within 60 days of the date can demonstrate that a grievance was filed with the insurer, or
  • received notification that [Healthplan] has agreed to waive the requirement to exhaust the internal appeal [and/or second level grievance process.]

If your request for a standard external review is related to a retrospective noncertification (a noncertification which occurs after you have received the services in question), you will not be eligible to request a standard review until you have completed [Healthplan's] internal review process and received a written final determination from [Healthplan].

If you wish to request a standard external review, you (or your representative) must make this request to NCDOI within 120 days of receiving [Healthplan's] written notice of final determination that the services in question are not approved. When processing your request for external review, the NCDOI will require you to provide the NCDOI with a written, signed authorization for the release of any of your medical records that may need to be reviewed for the purpose of reaching a decision on the external review.

Within 10 business days of receipt of your request for a standard external review, the NCDOI will notify you and your provider of whether your request is complete and whether it is accepted. If the NCDOI notifies you that your request is incomplete, you must provide all requested additional information to the NCDOI within 150 days of the date of [Healthplan's] written notice of final determination. If the NCDOI accepts your request, the acceptance notice will include:

  • the name and contact information for the Independent Review Organization (IRO) assigned to your case;
  • a copy of the information about your case that [Healthplan] has provided to the NCDOI;
  • notice that [Healthplan] will provide you or your authorized representative with a copy of the documents and information considered in making the denial decision (which will also be sent to the IRO); and
  • notification that you may submit additional written information and supporting documentation relevant to the initial noncertification to the assigned IRO within 7 after receipt of the notice of acceptance.

If you choose to provide any additional information to the IRO, you must also provide that same information to [Healthplan] at the same time using the same means of communication (e.g., you must fax the information to [Healthplan] if you faxed it to the IRO). When faxing information to [Healthplan], send it to [1-xxx-xxx-xxxx]. If you choose to mail your information, send it to:

[HEALTHPLAN]
[Address]
[City, State xxxxx-xxxx]

Please note that you may also provide this additional information to the NCDOI within the 7-day deadline rather than sending it directly to the IRO and [Healthplan]. The NCDOI will forward this information to the IRO and [Healthplan] within two business days of receiving your additional information.

The IRO will send you written notice of its determination within 45 days of the date the NCDOI received your standard external review request. If the IRO's decision is to reverse the noncertification, [Healthplan] will, reverse the noncertification decision within 3 business days of receiving notice of the IRO's decision, and provide coverage for the requested service or supply that was the subject of the noncertification decision. If you are no longer covered by [Healthplan] at the time [Healthplan] receives notice of the IRO's decision to reverse the noncertification, [Healthplan] will only provide coverage for those services or supplies you actually received or would have received prior to disenrollment if the service had not been noncertified when first requested.

An expedited external review of a noncertification decision may be available if you have a medical condition where the time required to complete either an expedited internal appeal or second level grievance review or a standard external review would reasonably be expected to seriously jeopardize your life or health or would jeopardize your ability to regain maximum function. If you meet this requirement, you may make a written or verbal request to the NCDOI for an expedited review after you:

For companies that utilize just one level of internal review:

  • receive a noncertification decision from [ Healthplan] AND file a request with [Healthplan] for an expedited appeal, or
  • receive an appeal decision upholding a noncertification decision.

For companies that utilize two levels of internal review

  • receive a noncertification decision from [Healthplan] AND file a request with [Healthplan] for an expedited appeal, or
  • receive an appeal decision upholding a noncertification decision AND file a request with [Healthplan] for an expedited second level grievance review, or
  • receive a second-level grievance review decision upholding the original noncertification.

You may also make a request for an expedited external review if you receive an adverse [second-level grievance review decision] [first level appeal decision] concerning a noncertification of an admission, availability of care, continued stay or emergency care, but have not been discharged from the inpatient facility.

In consultation with a medical professional, the NCDOI will review your request and determine whether it qualifies for expedited review. You and your provider will be notified within 3 business days if your request is accepted for expedited external review. If your request is not accepted for expedited review, the NCDOI may: (1) accept the case for standard external review if [Healthplan]'s internal review process was already completed, or (2) require the completion of [Healthplan]'s internal review process before you may make another request for an external review with the NCDOI. An expedited external review is not available for retrospective noncertifications.

The IRO will communicate its decision to you within 4 business days of the date the NCDOI received your request for an expedited external review. If the IRO's decision is to reverse the noncertification, [Healthplan] will, within one day of receiving notice of the IRO's decision, reverse the noncertification decision for the requested service or supply that is the subject of the noncertification decision. If you are no longer covered by [Healthplan] at the time [Healthplan] receives notice of the IRO's decision to reverse the noncertification, [Healthplan] will only provide coverage for those services or supplies you actually received or would have received prior to disenrollment if the service had not been noncertified when first requested.

The IRO's external review decision is binding on [Healthplan] and you, except to the extent you may have other remedies available under applicable federal or state law. You may not file a subsequent request for an external review involving the same noncertification decision for which you have already received an external review decision.

For further information about External Review or to request an external review, contact the NCDOI at:

By Mail:
NC Department of Insurance
Health Insurance Smart NC
1201 Mail Service Center
Raleigh, NC 27699-1201
(fax)919-807-6865

In Person:
Dobbs Building
430 N. Salisbury St.
1st Floor, Suite 1072
Raleigh, NC
855-408-1212 (toll-free)
www.ncdoi.com/Smart for External Review information and Request Form

The Health Insurance Smart NC Program is also available to provide assistance to consumers who wish to file an appeal or grievance with their health plan.

To be included in the section of letter that explains expedited appeal and 2nd level grievance:

If you believe you are eligible for and request an expedited appeal from [Healthplan], you may be eligible to request an expedited external review from NCDOI. Expedited external review is available if you have a medical condition where the time frame for completion of an expedited appeal with us would reasonably be expected to seriously jeopardize your life or health, or jeopardize your ability to regain maximum function. However, you must have also filed a request for an expedited appeal (even if you have not yet received a decision on the appeal) before NCDOI can accept your request for expedited external review.