Who should I call if I have any questions about filing a complaint?

You can contact the North Carolina Department of Insurance at (855) 408-1212. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

What happens after Smart NC receives my complaint?

Once your complaint is received, Smart NC will forward a copy of the complaint to your health insurer and require it to respond.[30] Smart NC will review your insurer’s response to determine whether its actions comply with all applicable laws, regulations,...

How do I file a complaint?

If you are a North Carolina resident and you believe your insurer did something illegal or unethical, you can file a complaint with the North Carolina Department of Insurance, Health Insurance Smart NC Division (“Smart NC”). Complaint information. Your complaint should...

How long will the external review process take?

The review process should take no more than 45 days from the date the review organization receives your request.[26] If you requested an expedited external review, the process should take no longer than three business days after receiving your request.[27]

How do I request an external review?

You should submit your request for an external review to the North Carolina Department of Insurance, Health Insurance Smart NC (“Smart NC”).[19] You must file your request within 120 days from the date that your insurer sent you its final decision.[20]...

In what circumstances can I apply for an external review?

During an external review, an independent third party reviews your insurer’s decision.[16] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under North Carolina law, you are entitled to request an...

How long should the appeal and grievance processes take?

The first level appeal or grievance should take a maximum of 30 days.[13] If you request a second level grievance, you should receive a decision within seven days following the hearing.[14] If you request an expedited appeal or grievance, you should receive...

How do I request an expedited appeal or grievance?

If waiting 30 days for your requested treatment or service would seriously jeopardize your life or health, you or your health care provider can request an expedited first level appeal or grievance.[10] Instructions on how to request an expedited appeal or...

How do I file a second level grievance?

If your insurer denies your claim after a first level appeal or first level grievance, you may (but are not required to) file a second level grievance with your insurer.[5] Your health care provider can submit the request for you.[6] Instructions for...

How do I file a first level grievance?

You can file a first level grievance with your health insurer if your insurer denies your requested service or treatment for any reason other than medical necessity. Reasons may include availability, delivery, or quality of health care services; payment of...

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