Health claim denials can be appealed in North Carolina.
About 20 percent of all health care claims are incorrectly processed, according to a 2010 study by the American Medical Association. Errors may involve overpayment or underpayment of a claim, or outright denial of a claim. To protect citizens of North Carolina against the wrongful denial of health claims, section 58-50-62 of the North Carolina General Statutes mandates that insurance companies provide an appeals process.
Instructions
The Appeals Process
1. Review your policy. You can only appeal claim denials for treatment that your insurance company determines is not medically necessary. You cannot appeal a denial if your medical condition or treatment is not covered by the policy.
2. Ask your physician to review the denial. It is possible that your insurance company misunderstood your need for a certain medical procedure. Have your physician review the denial and write a letter that further explains the necessity of treatment.
3. File an informal appeal. Many insurance plans in North Carolina have an informal appeals process that allows a policyholder to provide additional information to the insurer and seek a quick resolution to the dispute. Usually this involves simply calling the company and providing a letter of clarification from your physician.
4. File a first-level appeal. You will need to contact your insurance company and advise it that you wish to formally appeal the process. Within three days of receiving this request, the insurance company is required to provide you with the name of your appeal coordinator and instructions on submit supporting documents. A physician that was not involved in the original denial will review the claim. You will receive a decision within 30 days.
5. File a second-level appeal. If your first-level appeal is denied, the next step is to file a second-level appeal. In this step, a panel of disinterested experts will hold an administrative hearing to decide the outcome of your claim. The insurance company has 10 days to provide you with the contact information of the hearing coordinator. You can attend the hearing and present your case to the panel if you choose to. You will receive a decision within seven days.
6. Contact the North Carolina Department of Insurance (NCDOI). The NCDOI has an external review program that allows you to have the claim denial reviewed by medical professionals that are not associated with your insurance company. To qualify, you must first exhaust all appeals with the insurance company. To obtain an external review request form, call 877-885-0231 or go to the department’s website (see resources).
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