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External Review

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QUESTION: Who are the Health Insurance Smart NC (Smart NC) staff that will be working with the External Review Program?

ANSWER:
Susan D. Nestor, RN, MSN, Director
Luann Muntz, RN, Clinical Review Analyst
Connie Richeal, Clinical Review Analyst
Jacquie Buttles, Health Insurance Specialist II
Tammie Solomon, Health Insurance Specialist II
Caren McKoy, Administrative Assistant
Tiffany Bennett-Cornelous, Office Manager

The office phone number is: (919) 807-6860

QUESTION: How can consumers contact the Department to ask questions or request an external review?

ANSWER:
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
(toll-free) 1-877-885-0231

NOTE: For full text of NCGS 58-50-75 though 95, Health Benefit Plan External Review, visit the web site for North Carolina's General Assembly (www.ncga.state.nc.us) and select information on senate bill 1999 from the 2001 legislative session by entering "S199" in the field for "Bill Lookup #". External review is addressed in Part IV of the bill.

Product and Issue Eligibility

QUESTION: What products (i.e. HMO, PPO, etc.) are eligible for state mandated review?

ANSWER: NCGS 58-50-75(b) states that the law applies "to all insurers that offer a health benefit plan and that provide or perform utilization review pursuant to G.S. 58-50-61, the Teachers' and State Employees' Comprehensive Major Medical Plan, and the North Carolina High Risk Pool (Inclusive Health)."

QUESTION: What issues are eligible for external review, i.e. medical necessity, experimental / investigational, other?

ANSWER:

The issues eligible for external review include all appeal decisions upholding a noncertification or a second-level grievance review decision upholding a noncertification.

NCGS 58-50-61(a)(13) states " 'Noncertification' means a determination by an insurer or its designated utilization review organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based upon the information provided, does not meet the insurer's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, or does not meet the prudent layperson standard for coverage of emergency services in G.S. 58-3-190, and the requested service is therefore denied, reduced, or terminated. A 'noncertification' is not a decision rendered solely on the basis that the health benefit plan does not provide benefits for the health care service in question, if the exclusion of the specific service requested is clearly stated in the certificate of coverage. A 'noncertification' includes any situation in which an insurer or its designated agent makes a decision about a covered person's condition to determine whether a requested treatment is experimental, investigational, or cosmetic, and the extent of coverage under the health benefit plan is affected by that decision."

When an insurer denies a service that is absolutely excluded under a covered person's certificate of coverage because the plan always considers it experimental, is not eligible for external review because it is not a utilization review decision. However, when an insurer denies a requested service because it is deemed to be experimental based on the covered person's medical condition, the denial is a noncertification and therefore subject to appeal and ultimately external review if it continues to be denied.

QUESTION: If a covered person requests authorization of or coverage for services from an out-of-network physician when those same services are available from an in-network provider, and the health plan denies that request, is the denial eligible for external review?[new question, Feb. 2003]

ANSWER: In many cases involving a covered person's request for coverage for the services of an out-of-network provider, external review will not be available. However, the answer in any specific case is determined by the rationale for the covered person's request and the insurer's reasons for denying it.

External review provides an independent review of an insurer's second-level grievance decision upholding a noncertification or, in the case of a request for expedited external review, its noncertification or appeal decision upholding a noncertification. In all cases, the matter subject to external review stems from the insurer's initial noncertification issued pursuant to a utilization review (UR) process which is subject to NCGS 58-50-61.

If the insurer's decision not to cover a service was not based (entirely or partially) on a UR determination of the medical necessity of the service but, rather, was based only upon conditions and limitations of coverage under the covered person's benefit plan, then the insurer has issued an administrative denial rather than a UR noncertification. External review rights and the requirement to send notice of external review rights apply only in cases where a noncertification has been issued. Although an administrative denial may be a matter eligible to be filed as a "grievance" subject to the provisions of NCGS 58-50-62, and may even involve a clinical matter, external review is not available for insurer decisions on a grievance unless the matter related initially to a UR noncertification.

NCGS 58-50-61(a) sets out several definitions relevant to this question. Those relevant definitions read in whole or in pertinent part as follows:

  • Noncertification means a determination by an insurer or its designated utilization review organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based upon the information provided, does not meet the insurer's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, or does not meet the prudent layperson standard for coverage of emergency services in G.S. 58-3-190, and the requested service is therefore denied, reduced, or terminated. ... A noncertification includes any situation in which an insurer or its designated agent makes a decision about a covered person' s condition to determine whether a requested treatment is experimental, investigational, or cosmetic and the extent of coverage under the plan is affected by that decision.
  • Grievance means a written complaint submitted by the covered person about any of the following:
    1. An insurer's decisions, policies, or actions related to availability, delivery, or quality of health care services. A written complaint submitted by a covered person about a decision rendered solely on the basis that the health benefit plan contains a benefits exclusion for the health care service in question is not a grievance if the exclusion of the specific service requested is clearly stated in the certificate of coverage.
    2. Claims payment or handling; or reimbursement for services.
    3. The contractual relationship between a covered person and an insurer.
    4. The outcome of an appeal of a noncertification under this section.
  • Medically necessary services or supplies means those covered services or supplies that are:
    1. Provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease.
    2. Except as allowed under G.S. 58-3-255, not for experimental, investigational, or cosmetic purposes.
    3. Necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms.
    4. Within generally accepted standards of medical care in the community.
    5. Not solely for the convenience of the insured, the insured's family, or the provider...

QUESTION: Under what circumstance would a denial for out-of-network services be eligible for external review?[new question, Feb. 2003]

ANSWER: If the insurer considers the medical necessity of a service, including the medical necessity of obtaining a service from an out-of-network provider, then the decision is a noncertification and is subject to external review.

Listed below are some examples of possible reasons for requesting coverage of services from out-of-network providers, followed by discussion intended to provide insight into how the Department is likely to view such requests:

  • When a covered person and their insurer agree on the medical necessity of the requested service but do not agree on whether the network includes the type of provider that provides the type of service that is needed, the dispute likely does not involve a medical necessity determination. Therefore, the matter would typically be settled through the first-level grievance process, and, if offered and applicable, the second-level grievance process, with no opportunity for external review after the internal process has been exhausted.

    If your analysis of a dispute centers around NCGS 58-3-200(d) or 58-50-30, 11 NCAC 20.0300, and the contract language for the plan in question, it is likely that the case falls under this example.
  • When a covered person and their insurer agree on the medical necessity of the requested service but do not agree on whether any network provider(s) who perform(s) the type of service requested possess the type of training that is necessary to treat the covered person due to the covered person's personal characteristics, medical circumstances, etc., the dispute likely involves a medical necessity determination. (E.g., Whether a pediatric subspecialty is medically necessary for the provider performing the service in the specific case.) Following exhaustion of the internal appeal and, if the insurer offers one, the second-level grievance, external review would be available to the covered person.

    If your analysis of a dispute centers around the statutory definition of medically necessary services or noncertification, it is likely that the case falls under this example.
  • When a covered person and their insurer agree on the need for the requested service but do not agree on whether a network provider who performs the requested service is reasonably available, this may be considered a medical necessity determination under somewhat narrow circumstances, depending on the covered person's rationale for saying the network provider is not reasonably available. (E.g., If the argument is that the covered person's medical condition makes travel to the nearest network provider medically inappropriate and there is an out-of-network provider located closer by, the dispute may involve a medical necessity determination.) If the insurer makes a medical necessity determination, the dispute will be settled via the internal appeal process, which may include a second-level grievance, followed by an external review. If the dispute does not involve a medical necessity determination, the insurer's grievance process, including a first-level and, if offered and applicable, a second- level grievance, should be used to settle the matter. In this case, although the matter grieved may have a clinical aspect to it, external review would not be available. A key question to ask in this case is whether your analysis of the dispute centers around the statutory definition of medically necessary services or whether it centers around NCGS 58-3-200(d) or 11 NCAC 20.0300.
  • When an insurer's network provider(s) who are able to perform the requested services do not possess the same level of expertise and experience in the opinion of the covered person as a particular out-of-network provider that the covered person wishes to see, there would likely not be a dispute regarding a medical necessity determination so long as there was no disagreement between covered person and insurer regarding the medical necessity of the service itself. In this case, the matter should be resolved via the insurer's grievance process, including a first-level and, if offered and applicable, a second-level grievance. Although the matter grieved may have a clinical aspect to it, external review would not be available.

    A key question to ask in this case is whether your analysis of the dispute centers around the statutory definition of medically necessary services or "noncertification" and the policy language. Please note that the above list of examples is not intended to be exhaustive of all reasons why a covered person might seek coverage for services from an out-of-network provider nor a definitive statement of how a specific case will be viewed since unique circumstances of a case may result in a different determination. Every insurer must make its own judgment on whether to review a request under its UR program or elsewhere, and each request for the insurer to change its initial decision or action must be processed as either an appeal (for UR decisions) or a grievance. Once an insurer has made the decision to process a request as a grievance, it should not offer the covered person the opportunity for external review after the internal review process has been completed unless it believes that it erred in not treati ng the request as a UR decision from the start.

The Insurer's Role and Deadlines for Providing Information

QUESTION: In terms of the Healthplan's responsibility to provide information for an external review, what will the process be when the Department receives a request for external review?

ANSWER:

Standard Review

When a request is received from the insured, within ten days the department will complete:

  1. Notification to the insurer and forward a copy of the request for review to the insurer.
  2. The notice shall include a request for any information the Department requires to conduct a preliminary review to determine if the insured was covered by the insurer at the time the health care service was provided or requested, if the service that is the subject of the review appeared to be a covered benefit under the policy, if the insured exhausted the internal appeals process and that all the information required by the Department to process the request.
  3. Notify the insurer whether the request was accepted for review.
  4. If the request is accepted, notify the insurer of the assigned IRO and direct the insurer to provide to the IRO and to the covered person or authorized representative who made the request for external review on behalf of the covered person, within seven days of receiving the notice of the assigned IRO, the documents and any information considered in making the noncertification appeal decision or the second level grievance review decision.
  5. If the request is not accepted, notify the insurer of this decision.

Expedited Review

When a request is received from the insured, within three days the department will complete:

  1. Notification to the insurer that a request has been received for an expedited review and forward a copy of the request form or verbally convey the request information to the insurer.
  2. The notification shall include a request for any information the Department requires to conduct a preliminary review to determine if the insured was covered at the time the service was provided or requested, if the service appears to be a covered benefit under the policy and if a request for an expedited review was made to the insurer by the insured.
  3. Consult a medical professional to determine if the request should be reviewed on an expedited basis.
  4. Notify the insurer whether the Department has accepted the request.
  5. If accepted, assign an IRO to the review.
  6. Direct the healthplan to provide to the assigned IRO, as soon as possible, but within the same day as receiving the notice of the IRO assignment, the documents and information considered in making the noncertification, appeal or second-level grievance review decision electronically, or by telephone or facsimile or any other available expeditious method. A copy of the same information shall be sent by the same means or other expeditious means to the covered person or the covered person’s representative who made the request for expedited external review.

QUESTION: How quickly will insurers have to provide information on a case?

ANSWER: For a Standard Review, the insurer is required to deliver the requested information to the Department within three business days of receipt of the Department's written notice of the request for review and request for information. (See NCGS 58-50-80(b)(1).) If the consumer's request for external review is accepted, the insurer or its designee utilization review organization shall provide to the assigned Independent Review Organization (IRO), and to the covered person or authorized representative who made the request for external review on behalf of the covered person, within seven days of receipt of the notice, the document and any other information considered in making the noncertification appeal decision or the second-level grievance review decision. (See NCGS 58-50-80(b)(3).)

For an Expedited Review, the Department will notify the insurer that the request has been received and provide a copy of the request or verbally convey all of the information included in the consumer's request for review and request needed information from the insurer. The insurer is required to deliver the information to the Department not later than one business day after the request was made. (See NCGS 58-50-82(b)(1).)

QUESTION: What happens if the insurer misses the deadline to provide information to the Department or the IRO?

ANSWER: The external review will proceed. NCGS 58-50-80(e) states: "Failure by the insurer or its designee utilization review organization to provide the documents and information within the time specified in this subsection shall not delay the conduct of the external review. However, if the insurer or its utilization review organization fails to provide the documents and information within the time specified in subdivision (b)(4) of this section, the assigned organization may terminate the external review and make a decision to reverse the noncertification appeal decision or the second-level grievance review decision. Within one business day of making the decision under this subsection, the organization shall notify the covered person, the insurer, and the Commissioner."

QUESTION: NCGS 58-50-80(b)(3) states "If the covered person chooses to send additional information to the assigned independent review organization, then the covered person shall at the same time and by the same means, send a copy of that information to the insurer." Once the insurer has received this information, can the insurer respond to, add to, embellish, or expand the completeness or context of this information and forward that to the independent review organization? Can the insurer add additional information that might be helpful to the IRO reviewing the case? [new question, Sept. 2002]

ANSWER: No, the insurer cannot add any information to respond to, embellish, etc. the additional information provided by the covered person, nor can they add new information not already on the record as part of their earlier decisions on the requested coverage. The rationale for this decision is as follows:

  1. NCGS 58-50-80(b)(4) states that the Commissioner shall... "Notify the insurer in writing whether the request for external review has been accepted. If the request has been accepted, the notice shall direct the insurer or its designee utilization review organization to provide to the assigned organization, within seven days of receipt of the notice, the documents and any information considered in making the noncertification appeal decision or the second-level grievance review decision." [emphasis added] Therefore, if the information was not considered in making the noncertification, the insurer cannot include it as part of the documents and information being submitted to the IRO.
  2. The intent in having the covered person to submit additional information to both the insurer and IRO, is not to provide a venue for debate between the insurer and covered person, but to allow the insurer the opportunity to review this information and to reconsider their noncertification decision based on this information.

QUESTION: If the insurer does not believe an insured's request is eligible for external review, what mechanism is in place to communicate our disagreement on eligibility and any related eligibility issues? [new question, Sept. 2002]

ANSWER: The Smart NC Program accepts that there may be situations when, based upon the language in the Certificate of Coverage, a denial decision may not be based solely on a medical necessity determination and other factors may supercede the medical necessity element required for coverage of a service. For that reason, the Smart NC Program has revised the information request form which is sent to insurers to determine their insureds eligibility. The revised form asks the insurer to answer the following questions:

  1. Is this a self-funded plan? Yes/No
  2. Do you agree that the covered person was eligible for coverage at the time of the request? Yes/No
  3. Do you agree that this denial is eligible for external review? Yes/No
  4. Was this decision based solely on a medical necessity determination? Yes/No. If other factors were considered during the denial process, please list:
  5. The health plan’s reason for denial was based on which of the following determinations: Medical Necessity, Experimental/Investigational/Cosmetic. If other factors were considered during the denial decision, please explain.

The purpose of these questions is to identify a need for discussion with the insurer regarding eligibility issues as part of the preliminary review process, and prior to making an assignment to an IRO. For an expedited external review request, the discussions must commence quickly given the time frame requirements governing the expedited review process. Discussion of the issues will result in either a determination by the Smart NC Program that the insured is not eligible for external review, or that the Smart NC Program disagrees with the insurer's eligibility issue and assigns the case to the IRO. Please refer to the revised insurer notification form posted on the External Review - Industry web site

QUESTION: When an insured elects to submit additional information to an IRO for an expedited external review, what assurance does the insurer have that both the IRO and insurer have received the same information? [new question, Sept. 2002]

ANSWER: The insured is requested to provide any additional information to the Smart NC Program who will then forward the information on to the insurer and IRO. The Smart NC Program cannot require the insured to follow this process. If the insured chooses to provide the information directly to the IRO, then they must at the same time, and by the same means, send a copy of that information to the insurer. If the insured provides the information directly to the IRO, the IRO will notify the Smart NC Program of the information they have received. The Smart NC Program will then verify with the insurer that they have received the same information.

IRO Reviews

QUESTION: What is the turnaround time for the Insurer to implement the IRO's decision to overturn a noncertification decision?

ANSWER: For a Standard Review, NCGS 58-50-80(l) states "Upon receipt of a notice of a decision under subsection (k) of this section reversing the noncertification appeal decision or second-level grievance review decision, the insurer shall within three business days reverse the noncertification appeal decision or second-level grievance review decision that was the subject of the review and shall provide coverage or payment for the requested health care service or supply that was the subject of the noncertification appeal decision or second-level grievance review decision."

For an Expedited Review, NCGS 58-50-82(f) states that "Upon receipt of a notice of a decision under subsection (e) of this section that reverses the noncertification, noncertification appeal decision, or second-level grievance review decision, the insurer shall within one day reverse the noncertification, noncertification appeal decision, or second-level grievance review decision that was the subject of the review and shall provide coverage or payment for the requested health care service or supply that was the subject of the noncertification, noncertification appeal decision, or second-level grievance review decision.

QUESTION: What happens if an insurer disagrees with the IRO's decision to overturn a noncertification?

ANSWER: Pursuant to NCGS 58-50-84, the decision of the IRO is binding on the insurer. Therefore, the insurer must reverse its denial and provide coverage once notified of an IRO's decision to overturn the noncertification.

An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or State law. Additionally, a covered person may not file a subsequent request for external review involving the same noncertification appeal decision or second-level grievance review decision for which the covered person has already received an external review. (See NCGS 58-50-84.)

QUESTION: What if the insurer reconsiders the case after being notified of the request for expedited review; can the insurer reverse its own decision?

ANSWER: Yes, if the decision is based upon consideration of new information provided by the covered person during the external review process. If the insurer decides to reverse its decision, it must notify the covered person, the IRO, and the Department. Immediately upon receipt of written notice from the insurer, the IRO shall cease its review of the case. (See NCGS 58-50-80(g) & (h).)

Funding and Fees

QUESTION: Who pays for the external review?

ANSWER: The insurer pays the fee charged by the IRO in conducting the external review.

NCGS 58-50-92 states "The insurer against which a request for a standard external review or an expedited external review is filed shall reimburse the Department of Insurance for the fees charged by the organization in conducting the external review, including work actually performed by the organization for a case that was terminated due to the insurer's decision to reconsider a request and reverse its noncertification decision, prior to the insurer notifying the organization of the reversal pursuant to NCGS 58-50-80(j), or when a review is terminated pursuant to NCGS 58-50-80(h) because the insurer failed to provide information to the review."

Upon receipt of the IRO's invoice, the Department will bill the insurer for reimbursement. The insurer is required to pay the Department in full within 15 days of date of invoice.

QUESTION: What cost is there if the insurer reverses its own decision?

ANSWER: Generally, the cost depends on when the reversal occurred in the external review process:

  1. The review has been received by the Department but not yet assigned to an IRO - NO FEE.
  2. The case is assigned to an IRO, but the clinical reviewer has not started the review – No/fee or IRO's Cancellation Fee.
  3. The case has been assigned to an IRO, and the review is underway or complete – Cancellation fee or IRO Case Fee

Individual IRO contracts may include timeframes which are specific to the cancellation fee. (Rev. 9/09)

QUESTION: Can the insurer reverse its decision on an expedited external review based upon new information received? If so, will the charge from the IRO be limited to a cancellation fee? [new question, Sept. 2002]

ANSWER: The insurer can reverse its original noncertification decision at any time during the external review process. However the review does not terminate until the IRO is notified in writing by the insurer of the reversal. Due to the expedited time frame that the review is conducted under, there is no guarantee that the insurer will incur lesser charges upon their reversal.

IRO Assignment and Information Disclosure

QUESTION: Who selects the IRO that is assigned to a case?

ANSWER: Pursuant to NCGS 58-50-80(b)(3)(5), the Department will assign cases to IROs using an alphabetical rotation system and after screening to determine that no conflict of interest exists between the insurer and the IRO. If an IRO is not capable of reviewing the type of services associated with a particular case (e.g., the case involves mental health services, but the IRO does not have mental health professionals among its network of medical reviewers), the next IRO on the alphabetical list will be assigned to the case.

QUESTION: When are insurers required to disclose information about external review to insureds?

ANSWER: Information about the right to external review must be included in the insurer's notice of a noncertification decision and notice of a decision on appeal and second-level grievance review when the decision is to uphold the original noncertification. The insurer is also required to a advise the insured of their rights to external review, and provide a general description of the external review process in the member policy, booklet, or evidence of coverage.

Statutory Time Periods

QUESTION: A covered person may file a request for an external review within 120 days after the date of receipt of a notice. How will the Department determine the date of receipt of notice?

ANSWER: To allow for time associated with an insurer's processing and mailing time, the Department will generally assume that a request for external review that is received within 130 days of the date that appears on the insurer's notice of decision on second-level review was made within the statutory time limits. However, documentation of date of receipt (e.g., certified mail receipt) that is provided by the insurer or the covered person may result in a request being denied though received within 130 days or accepted though received after 130 days. (Eff. 10/1/09)

QUESTION: NCGS 58-50-80(l) requires insurers, upon receipt of an IRO's notice of decision that reverses a noncertification decision, to provide coverage or payment for the requested health care service or supply within three business days. Please clarify the Departments expectations on this issue.

ANSWER: The law requires insurers to "provide coverage or payment" within three business days [emphasis added]. Insurers are urged to send payment within three business days in those cases where a claim had already been received. At a minimum, within three days of the notice of decision, insurers are required to send written notice of coverage to the insured and their provider and, if the insurer had already received a claim, issue an immediate release of the claim for payment. If the insurer has not yet received a claim, payment must be made in accordance with NCGS 58-3-225, the Prompt Pay Law, once the claim is received.

It will be the practice of the Smart NC Program staff to request from the insurer a copy of the notice of coverage sent to the insured and a copy of the claim check, Explanation of Benefits, or provider Remittance Advice as evidence of payment. This will enable the Smart NC staff to close out the insured's file and will also allow the Department to monitor the time that insurer's take to make payment.

Cases handled on an expedited basis are subject to the same requirements as outlined above, expect that pursuant to NCGS 58-50-82(f) the coverage or payment must be made within one calendar day of the insurer's receipt of the IRO's decision to overturn a noncertification.

QUESTION: Please explain how the requirements for insurers to submit information concerning a request for external review as set out in NCGS 58-50-80(b)(1) and (4) relate to the ten-day time period within which the Department must assign a case to an IRO.

ANSWER: NCGS 58-50-80(b)(1) requires insurers to, within three business days of receiving notice from the Department that a covered person has made a request for external review, provide to Department staff information necessary for the Department's eligibility review. This information exchange takes place within the ten-day period for eligibility review and assignment. After the case has been accepted for review and assigned to an IRO, an insurer shall, within seven days of receiving notice that the case has been accepted and assigned to an IRO, provide all information relating to the utilization review and appeal and grievance processes for the request to the IRO and to the covered person or authorized representative who made the request for external review on behalf of the covered person. Therefore, this information will not be able to be provided until the end of the period for eligibility review and assignment.

NCGS 58-50-82(b)(1), which addresses expedited external reviews, requires insurers to provide information necessary for the Department's eligibility review within one day of receiving notice that an external review has been requested. Once a case has been accepted for expedited external review, pursuant to NCGS 58-50-82(c), the insurer must provide the assigned IRO with information relating to its utilization review and appeals review of the case. This information is to be provided in an expeditious manner (by phone, fax, or other electronic means) within the same day that the insurer receives notice from the Department that the case has been assigned to an IRO. Both of these information exchanges take place within three days of the Department's receipt of the request for expedited external review.

QUESTION: How will requirements for same-day handling under NCGS 58-50-82(c) be treated - on a 24-hour or calendar day basis?[answer revised Sept. 2002].

ANSWER: NCGS 58-50-82(c) requires the information to be submitted by the insurer "within the same day of receiving" notice that the case has been assigned to an IRO. NCGS 58-50-82(b) requires that the Smart NC Program assign a case to an IRO "within three days of receiving a request." The combination of these two provisions have the effect of putting all information about an accepted case in the hands of the assigned IRO within three days of the Smart NC Program's receipt of a request. (Note: This requirement is in addition to the insurer meeting other interim deadlines regarding a request for expedited external review and has no effect on those other deadlines.)

The Department recognizes that insurers may face practical challenges in meeting the time requirements of the expedited review process and therefore will endeavor to assign cases prior to the third day of receipt of a request whenever it is able to do so and will define "same day" in a manner to provide the greatest possible time in each specific case while still complying with the law. Therefore, insurers will be required to provide the requested information to the assigned IRO no later than the time frame, which is the earliest of one of the following time frames:

  • Within one business day of receiving notice from the Smart NC Program that the case has been assigned (would apply when the case is assigned on any day before the third business day after the Smart NC Program's receipt of request for expedited external review)
  • By 5 p.m. of the day of notice of assignment if the Smart NC Program is making assignment to the IRO on the third business day after receipt.

In order to remove any confusion over the deadline that will apply in a specific case, the letter from the Smart NC Program advising that a case has been assigned to an IRO will specify the applicable deadline for providing information.

QUESTION: How long does a covered person have to add missing information to a request for external review that has been found to be incomplete?

ANSWER: NCGS 58-50-80(c) requires that any incomplete request be made complete by the 150th day following the covered person's receipt of the insurer's decision that is the subject of the request for external review.(Eff. 10/1/09)

Other FAQs

QUESTION: When reviewing a request for expedited external review that is made prior to the covered person having completed the insurer's internal appeal and grievance process under what circumstances would the Department's consulting physician determine that external review is medically appropriate and therefore permissible under the law, knowing that the insurer's own expedited review is underway?

ANSWER: NCGS 58-50-82(a)(1) allows covered persons to request expedited external review upon receipt of an insurer's initial notice of noncertification, so long as they have also already filed an expedited appeal with the insurer. In deciding whether the covered person's request for expedited external review should be accepted immediately or whether the insurer's expedited appeal process should first be completed, the Department's consulting physician will consider whether the time frame for completing both the expedited appeal and potential external expedited review (in the event that the decision on appeal is to uphold the noncertification) poses a greater risk of seriously jeopardizing the life or health of the covered person or jeopardizing the covered person's ability to regain maximum function than does the time frame for immediate external review. If the risk would be increased by requiring the internal appeal process to be completed, the request will be accepted for expedited external review.

NCGS 58-50-82(a)(2) allows covered persons to request expedited external review upon receipt of an insurer's notice of determination on a first-level appeal, so long as they have also already filed an expedited second-level grievance with the insurer. In deciding whether the covered person's request for expedited external review should be accepted immediately or whether the insurer's expedited second-level grievance process should first be completed, the Department's consulting physician will consider whether the time frame for completing both the expedited second-level grievance and external expedited review (in the event that the insurer's decision on the second-level grievance is to uphold the noncertification) poses a greater risk of seriously jeopardizing the life or health of the covered person or jeopardizing the covered person's ability to regain maximum function than does the time frame for immediate external review. If the risk would increase by requiring the internal second-level grievance process to be completed, the request will be accepted for expedited external review.

QUESTION: How will the Department determine when a provider who requests an external review on behalf of a covered person is doing so on the authority of the covered person?

ANSWER: The Department will develop internal procedures to verify authorization, including requiring completion of an authorization form when the covered person is capable of completing such a form.

QUESTION: What "aggregate" records and records "for each type of health benefit plan offered by the insurer" regarding requests for external review are insurers required to keep under NCGS 58-50-90(e)?

ANSWER: At present, the Department is not expecting insurers to keep "aggregate records" or records "for each type of health benefit plan offered by the insurer", since the Department's and each contracted IRO will have records capable of providing aggregate information on requests relating to individual insurers.

Insurers are reminded that they must maintain records of handling for each individual case involving a request for external review sufficient to demonstrate compliance with the requirements of NCGS 58-50-75 through 93. These records are to be maintained for a period of three years or until the completion of the next market conduct examination, whichever is later.

QUESTION: Will the covered person or their authorized representative be permitted to submit additional information once notified that their expedited external review case has been assigned to an IRO? [new question, Sept. 2002]

ANSWER: The law is silent on the provision of additional information by the covered person, the and therefore provides no information on the timing of providing such information. Therefore, for practical reasons and to ensure that the assigned IRO is provided with all information relating to the case not later than by the end of the third day following the Smart NC Program's receipt of a request for expedited external review, the deadline that applies to the insurer providing information to the IRO will also be applied to the covered person providing additional information to the IRO. Consistent with requirements pertaining to the process for standard external review, additional information from the covered person must be provided to the insurer at the same time and in the same manner as it is provided to the IRO. In order to ensure that this requirement is met, covered persons will be strongly encouraged to submit additional information, if any, directly to the Smart NC Program for forwarding to the IRO and insurer.

QUESTION: What is the role of the Medical Professional (physician) in working with the external review process? [new question, Sept. 2002]

ANSWER: The role of the Medical Professional is to provide case evaluations of expedited external review requests for the State's independent external review program. The scope of these evaluations is limited to determining whether a request meets medical criteria for expedited review.

With regard to request for expedited external review immediately following a covered person's receipt of a noncertification decision, NCGS 58-50-82(b)(2)(a) states that "For a request made pursuant to subdivision (a)(1) of this section that the Commissioner has determined meets the reviewability requirements set forth in G.S. 58-50-80(b)(2), determine, based on medical advice from a medical professional who is not affiliated with the organization that will be assigned to conduct the external review of the request, whether the request should be reviewed on an expedited basis because the time frame for completion of an expedited review under G.S. 58-50-61(1), or would reasonable be expected to seriously jeopardize the life or health or the covered person or would jeopardize the covered person's ability to regain maximum function."

With regard to request for expedited external review following a covered person's receipt of an appeal decision upholding a noncertification, NCGS 58-50-82(b)(2)(b) states that "For a request made pursuant to subdivision (a) (2) of this section that the Commissioner has determined meets the reviewability requirements set forth in G.S. 58-50-80 (b)(2), the Commissioner shall determine, based on medical advice from a medical professional who is not affiliated with the organization that will be assigned to conduct the external review of the request, whether the request should be reviewed on an expedited basis because the time frame for completion of an expedited review under G.S. 58-50-62 would reasonably be expected to seriously jeopardize the covered person's ability to regain maximum function."

With regard to request for expedited external review following a covered person's receipt of a second-level grievance decision upholding a noncertification, NCGS 58-58-82 (b)(2)(c) states "For a request made pursuant to sub-subdivision (a) (3) a. of this section that the Commissioner has determined meets the reviewability requirements set forth in G.S. 58-50-80 (b)(2), the Commissioner shall determine, based on medical advice from a medical professional who is not affiliated with the organization that will be assigned to conduct the external review of the request, whether the request should be reviewed on an expedited basis because the time frame for completion of a standard external review under G.S. 58-50-80 would reasonably be expected to seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function.