The purpose of the Healthcare Review (HCR) Unit is to provide for the independent medical review of health plan coverage denials that North Carolina law grants our citizens. HCR’s primary responsibility is to receive and process requests for external review and assign accepted cases to contracted independent review organizations (IROs). HCR contracts with and oversees the IROs who perform the reviews.
HCR is also responsible for providing counseling to consumers regarding appeals to their health plan (i.e. “internal appeals”).
Unit staff answers questions from consumers, physicians, hospital representatives, insurers, agents and other DOI Divisions and staff regarding consumer appeals to health insurers as well as the external review process provided through DOI.
|Question: 1. What is external review?|
|Answer: External review refers to an independent medical review of certain decisions made by health insurers. These reviews are arranged for by the North Carolina Department of Insurance Healthcare Review Program (HCR Program). The HCR Program contracts with several companies known as Independent Review Organization (IROs). IROs have large networks of physicians and other types of medical professionals qualified to evaluate a wide range of medical issues. The IRO assigned to your case and its medical reviewers will have no relationship with your health insurer. The IRO makes the final coverage decision on each request that the HCR Program has determined eligible for external review. If the IRO medical reviewer for your case determines that the requested service is medically necessary, your insurer will be required to approve or pay for your previously denied service.|
|Question: 2. What kind of insurer decisions are subject to external review?|
|Answer: External review is available when your health insurer denies coverage for services or requested services on the grounds that they are not medically necessary. This type of denial is often called a “noncertification decision.” A decision by your insurer that services are not covered because they are cosmetic or experimental in your case because of your specific medical circumstances, rather than because it is absolutely excluded under your insurance policy, is also a noncertification decision subject to external review.|
|Question: 3. Can I request a review for any type of insurance denial?|
|Answer: External review is available for most health insurers that make coverage decisions based on medical necessity. Other types of denial decisions are not eligible for external review.
Medical necessity decisions made by the NC Teachers’ and State Employees Comprehensive Major Medical Plan (State Health Plan) and the NC Health Insurance Program for Children (NC Health Choice) are also subject to external review.
External review does not apply to self-funded employer health plans. (These are health plans for which an employer sets aside his own funds to pay for health claims rather than purchasing insurance, and are often “administered” by health insurance companies.) External review also does not apply to Medicare or Medicaid and is not available for certain types of insurance, including: dental, vision, Medicare supplement, long-term care, specified disease, workers compensation, credit, or disability income, or to medical payments under homeowners or auto insurance.
|Question: 4. When can I request an external review?|
|Answer: External review is available whether you have already received a service and coverage for it has been denied or you have requested and been denied coverage for a service that you have not yet received.
Most people will qualify for a standard external review, which results in a decision within 45 days of submitting a request for review. An expedited external review, under which a decision is made within four business days of submitting a request, is available in cases where the time involved in obtaining a final decision can have an impact on a person’s health. The specific eligibility requirements for expedited review and a detailed description of the standard and expedited review processes are explained in the next several questions and answers.
|Question: 5. When can I request a standard external review?|
|Answer: You may request a standard external review after you have exhausted your health insurer’s internal appeal process. Some health insurers offer one level of appeal and some offer two levels. Consult your insurance policy or member handbook to determine how many levels of appeal your insurer offers or requires.
You must make your request to the HCR Program within 120 days of receiving notice of your insurer’s final decision from the highest level of appeal offered, that your request for coverage remains denied by your insurer. To allow for mailing time and time that you may not have been available to receive your notification from your health insurer, the HCR Program will accept your request up to 130 days after the date on the notice of decision on appeal. (Eff. 10/1/09)
There are two exceptions to the requirement that you complete your health insurer’s appeal process. 1.) In some cases, your insurer may choose to waive some or all of its internal appeal process to allow the denial to proceed to external review. If your health insurance company has notified you in writing that it agrees to waive its appeal process, you may request an external review within 60 days of receiving this notification. 2.) If you filed a second-level appeal with your insurer more than 60 days ago and have not received a response and have also not agreed to give the insurer additional time to respond, you may request an external review. If your insurer offers just one level of appeal, you may request an external review if you have not received any response from the insurer within 60 days filing the appeal.
|Question: 6. When can I request an expedited external review?|
|Answer: Expedited review is available only when having to first complete your insurer’s internal appeal process (even on expedited basis) or receiving a standard external review through the HCR Program would put your life, health, or recovery in serious jeopardy. Therefore, you may request an expedited external review immediately after receiving your initial denial notice (noncertification) or after receiving notice of your insurer’s decision to continue its denial after considering your first-level or second-level appeal. We anticipate that most requests for expedited external review will be made very soon after a person receives the insurer’s initial notice of denial or denial decision on appeal, but any request to the HCR Program must be made within 120 days receiving your most recent denial from your insurer. To allow for mailing time and time that you may not have been available to receive your notification from your health insurer, the HCR Program will accept your request up to 130 days after the date on the notice of decision on appeal. (Eff. 10/1/09)
You are not required to exhaust your insurer’s appeals process prior to requesting expedited external review, but you must have already requested an expedited appeal from your insurer prior to requesting external review from the HCR Program. If you have already received a decision on a first-level appeal and now wish to request expedited external review, you must have already requested an expedited second-level appeal from your insurer (if your insurer offers one) prior to requesting the external review.
To determine whether your case qualifies for expedited external review, the HCR Program will 1) verify that you have initiated an expedited appeal with your insurer and 2) consult a medical professional to determine if the time required to first complete the insurer’s expedited appeal process before requesting external review is likely to put your life or health or ability to regain maximum function in serious jeopardy. If the HCR Program determines that your request does not qualify for expedited external review, you may be required to first complete your insurer’s appeal process.
If you have already completed your insurer’s appeal process and your insurer has issued its final decision denying the requested service, you may request an expedited external review if the time for a standard external review through the HCR Program would put your life, health or ability to regain maximum function in serious jeopardy. If the HCR Program determines that your case does not qualify for expedited review, it may still qualify for a standard external review.
Please note: Expedited external review is not available if you have already received the services for which coverage has been denied. If you believe you need to make a request for an expedited review, you may call the HCR Program for guidance in making your request.
|Question: 7. What are the eligibility requirements to request an external review?|
|Answer: In order for your request to be eligible for external review, the HCR Program must determine that all of the following criteria have been met:|
|Question: 8. How do I request an External Review?|
For a standard review:
You may call the HCR Program toll-free in North Carolina at 1-877-885-0231 or locally at 919-807-6860 and ask that a request form to be mailed to you. You may also pick up a request form in person at the Healthcare Review Program office. The address is:
North Carolina Department of Insurance
You may access the External Review Request Form from the Department of Insurance web site at www.ncdoi.com. This is an interactive form into which you can enter information. All the fields on the request form must be completed so that the HCR Program can access your information from your insurer or your healthcare provider and determine whether your request is eligible for review. Print and sign the printed copy and send it to the HCR Program. You cannot submit this form to the HCR Program via email.
You must provide the following documents to the HCR Program in order for your request to be considered complete:
|Requests may be mailed to:
North Carolina Department of Insurance
|For expedited review:
The request form that is required for a standard review is also required for an expedited external review. This form contains the information that is required for the HCR Program to access your insurance information and process your request. Also, you will be required to submit a signed Medical Records Release Form to the HCR Program, so that we access any medical documents that are required to help make a determination on your request. Contact the Program as follows:
In state Toll-free: 1-877-885-0231
You may request an expedited review by faxing the completed request form to the HCR Program at 919-807-6865 during regular business hours which are 8:00am – 5:00pm Monday – Friday, or sending the request to the Healthcare Review office at the address above. (Eff. 10/1/09)
|Question: 9. Must I request an external review myself?|
|Answer: No. You may designate any person you wish, including your health care provider, as your Authorized Representative to act on your behalf in pursuing an external review. The Request for External Review Form includes a section on contact information for an authorized representative. Be sure that this information is included if someone will be acting as your representative.
In the case of a minor or someone deemed incompetent, a request must be made by a parent, conservator, guardian, health care power-of-attorney or any individual who has been designated as the patient’s authorized representative.
|Question: 10. After I request an external review, when should I expect to hear something?|
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, the HCR Program will ask you to provide the required information within 90 days of the date you received your final determination from your health plan. If the HCR Program 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 the HCR Program 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 the HCR Program 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 the HCR Program 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.)
If 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, the HCR Program 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 the HCR Program. 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 the HCR Program that:
|Question: 11. What documents should I provide that will help the IRO make a determination?|
|Answer: You have an opportunity to provide the IRO any additional information that you think helps makes the case that the services that were denied were medically necessary. Examples of these documents might include:|
|Question: 12. What happens when an external reviewer makes a decision?|
|Answer: The IRO notifies you, your healthcare provider, the HCR Program, and your health insurer when it makes a decision on your request. If the IRO’s decision overturns your health insurer’s original decision, the health plan must provide for coverage or payment within three days for a standard external review request and within one day for an expedited external review request. This decision is binding on you and your health plan. If the IRO’s decision is to agree with your health insurer’s original decision, you may not request another review on this case. The decision is binding on you and your insurer except to the extent you may have other remedies available under applicable federal or state law.|
|Question: 13. Will I have to pay for the external review?|
|Answer: There is no cost for the person who requested the external review. The HCR Program pays the IRO for its services and your health insurer will be required to reimburse the Program for the cost of the review.|
|Question: 14. Who conducts the external review?|
|Answer: The external review is conducted by an organization called an Independent Review Organization (IRO). IROs are contracted with the HCR Program to perform impartial reviews of your case to determine the merits of your request and to determine if your request should be covered under your policy. The doctors or medical professionals who review your request are Board Certified Specialists and have the same or similar background as the doctors or medical professionals who provided or requested your care. They will review your insurance coverage policy, as well as the medical documents and other information supplied to them by you and your insurer for review. Your request will be considered against the standard of practice in the medical community. IRO decisions will be made based upon supporting clinical evidence, standards of practice and personal experience of the specialty reviewer.|