For standard review:
Within 10 business days after requesting external review, you will receive notification whether the request is complete and whether it has been accepted for review.
If the request is incomplete, Smart NC will ask you to provide the required information within 90 days of the date you received your final determination from your health plan. If Smart NC does not receive the information within this time frame, your request will be considered ineligible and you will not be able to request a review for that specific service again.
If your request is complete Smart NC will advise you of whether your case has been accepted for external review. If accepted, you will be provided with the name of the IRO assigned to the case and given a copy of the information that was provided to Smart NC by your health insurer. You will also be notified at that time that you have seven days in which to provide the IRO any additional information that you feel would help the IRO make a determination. You may submit this information directly to the IRO or send it to Smart NC for timely forwarding to the IRO. If you choose to submit additional information directly to the IRO, you must also provide the same information to your health insurer at the same time and by the same means. (For example, if you are faxing information to the IRO, you must also fax information to your health insurer.)
f you do submit additional information, your health insurer will have the opportunity to consider the information and, if it chooses, reverse its own denial. If this does occur, the insurer will inform you and the IRO of this decision and the IRO will stop the external review. However, this "reconsideration " process will not slow down the external review and will not affect it if your insurer does not change its decision as a result of the new information.
Upon making its decision, the IRO will notify you in writing of its decision. This will be no more than 45 days after the HCR Program received your request.
For an expedited review:
Within three business days after you make your request, Smart NC will notify you whether your request meets the criteria for an expedited review. This decision will be made in consultation with a medical professional. If your request was accepted, you will be given the name of the IRO assigned to your case.
You will receive verbal or written notification of the IRO's decision within four business days of making your request to Smart NC. If you receive a verbal notification from the IRO, you will receive a written notification of their decision within two days of their verbal notification.
If your request was not accepted for external review, you will be notified by Smart NC that:
- you must first complete your health insurer's appeal process (or expedited appeal process) before the request is eligible for external review; or
- your request is accepted for standard rather than expedited external review; or
- your request is not eligible for external review of any kind.