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External Review

Industry Information

Member Notice Language (Changes in red effective 10/01/2009)

North Carolina law provides for the review of noncertification decisions by an external, Independent Review Organization (IRO). Except for cases when you request an expedited appeal (as outlined elsewhere in this letter), external review is available to you only after you have completed [Company's] internal appeal [and grievance] process. You or an authorized representative must make a request to the North Carolina Department of Insurance (NCDOI) for an external review within 60120 days of the date of the notice of [noncertification] [final determination]. The NCDOI administers this service at no charge to you and will arrange for the review of your case by an IRO once the NCDOI establishes that your request is complete and eligible for review.

Please review the External Review Provision in your [member certificate, member handbook, outline of coverage ] for a complete description of the external review policies and procedures including information about when an expedited external review is available, or you may request a copy from our Customer Service Department at [toll phone number]. [Optional Sentence: Please review the enclosed copy of the description of external review policies and procedures.]

NCDOI is also available to help you understand external review policies and procedures and your right to request an External Review under North Carolina law. To request an External Review or if you have additional questions about your right to an External Review, contact the NCDOI at:

North Carolina Department of Insurance
Health Insurance Smart NC
1201 Mail Service Center
Raleigh, NC 27699-1201
1-877-885-0231 (toll free)
1-919-807-6860
1-919-807-6865 (fax)
www.ncdoi.com/Smart for External Review information and Request Form

Health Insurance Smart NC is available to provide Consumer Counseling assistance on utilization review and the insurer's internal appeals and grievance issues.

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.