| Consumer Counseling on Appeal and Grievance Issues |
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| If you need assistance because your insurance company has denied you medical services, we may be able to help. |
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| Under North Carolina law, you have the right to appeal the insurance company’s decision to deny your treatment. Here are some things you should know about your rights: |
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- You can appeal if the company decided your treatment was not medically necessary.
- Your company cannot punish you for appealing! They cannot cancel your policy, they cannot raise your rates — they can’t do anything to “get back at you” because you appealed.
- Generally you have one or two chances to appeal the decision directly with the insurer — the first-level appeal and (if your insurer offers one) the second-level appeal (sometimes called a second-level grievance).
- Even if you lose the first appeal, you may want to consider appealing again if your insurer offers a second-level appeal. The people involved in your second-level appeal will not have anything to do with the first, so they will look at your case with fresh eyes. Completing all levels of internal appeals offered by the insurer is one of several requirements you would have to meet in order to be eligible for external review, should you wish to request one in the event that your appeals are not successful.
- If you lose your appeals, you may be eligible for an External Review through the Department of Insurance. Click here to learn more.
- External Review is completely free for you.
- Of the people who went through the External Review process, close to one-half won their cases.
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| The Department of Insurance Healthcare Review Program (HCR) provides counseling to consumers on appeals, grievances and utilization review issues. The Program staff of professional nurses can help you understand your insurance company’s process and suggest resources as you approach your appeal. Call our office if you have received a denial for medical services from your insurance company. |
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| IN-STATE TOLL FREE: 1-877-885-0231 |
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| WHAT WE CAN DO TO HELP YOU |
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Review with you information received from your insurer and identify issues of importance relating to your appeal and grievance process. |
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Provide you with information on North Carolina law governing the utilization review process and noncertification appeals. |
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Suggest general resources that may provide supporting information of your denial in the appeal process. |
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Explain how collaborating with your physician can assist with the appeal process. |
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Educate you regarding any appropriate statutes regarding your case. |
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Refer any regulatory or compliance issues to the Consumer Service Division for appropriate action. |
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Provide a written brochure about appeals entitled “A Guide to Appeals and Grievances: Your Rights As A Health Insurance Consumer”. |
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Explain the role of external review as it relates to your appeal. |
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| WHAT WE CAN NOT DO |
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Give an opinion regarding the appropriateness of the treatment. |
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Suggest alternate modes of treatment. |
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Provide specific, personalized, detailed information to include in the appeals effort. |
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Give medical advice. |
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Build a case for you. |
Address:
NC Department of Insurance
Healthcare Review Program
1201 Mail Service Center
Raleigh, NC 27699-1201
Phone:
(919) 807-6860
1-877-885-0231 (toll free in-state)
(919) 807-6865 (fax)
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