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State guide

North Carolina

Pick the kind of plan you have to see who to call first. North Carolina can only help with plans it regulates.

On this page 8

Which plan do you have? Who to call first, by coverage

  • Your employer pays claims itself

    North Carolina usually cannot help with these plans. Call the Employee Benefits Security Administration.

    Call 1-866-444-3272

  • Insurance you buy, or an employer plan bought from an insurer

    Call North Carolina Department of Insurance (Health Insurance Smart NC). See the at-a-glance box.

    Call 855-408-1212

  • Medicaid or children's coverage

    Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in North Carolina.

    Medicaid in North Carolina

  • Medicare

    Seniors' Health Insurance Information Program (SHIIP), North Carolina Department of Insurance gives free counseling. Or call 1-800-MEDICARE.

    Call 855-408-1212 1-800-633-4227

The short version for North Carolina

North Carolina's Department of Insurance runs a free consumer help program called Health Insurance Smart NC that will review your denial letter, explain your rights and handle external review requests. State external review is limited to medical necessity denials on state-regulated plans: it does not cover self-funded employer plans, Medicare or Medicaid. Denial letters on regulated plans must include Smart NC's contact information, and expedited external reviews are decided within about four business days.

At a glance: independent review for plans North Carolina regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
North Carolina Department of Insurance (Health Insurance Smart NC) · 855-408-1212
Independent review
A state process (External Review (by an Independent Review Organization))
Deadline to request it
120 days after you receive your insurer's final decision on appeal. For an expedited review, 120 days after the initial denial or the appeal decision.
Cost
None. The Department of Insurance calls external review a free service.
Decision time
45 days from the date Smart NC receives your request; fast track: Smart NC decides within 3 business days whether your request qualifies, and the reviewer's decision comes within 4 business days of your request

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

Independent (external) review

Process
A state process. Run by North Carolina Department of Insurance, Health Insurance Smart NC, which assigns each case to an independent review organization on a rotating basis.
Where you file
regulator
How
Fill out the External Review Request Form online (standard requests only) or print, sign and mail or fax the paper form to Health Insurance Smart NC, 1201 Mail Service Center, Raleigh NC 27699-1201. For an expedited review, use the paper form and have your doctor complete and sign the Physician Certification Form (Attachment A). Smart NC can be reached toll free at 855-408-1212.
Which denials qualify
Denials where your insurer decided a service was not medically necessary (called a noncertification). The service must appear to be a covered benefit, and you must have had coverage in effect when the service was requested or provided. Other kinds of denials, such as services your policy excludes, are not eligible. The plan must be state-regulated: self-funded employer plans, Medicare, Medicaid, and dental, vision, Medicare supplement, long-term care, specified disease, workers compensation, credit and disability income coverage are excluded.
Appeal to the plan first?
Yes for standard review: you must finish your insurer's internal appeal process. For expedited review you must meet the medical criteria (waiting would affect your health), have requested an expedited appeal with your insurer, and have your doctor certify the urgency; you do not have to wait for the standard appeal to finish.

Official page Request form

General rules and what to send: how external review works, how to request it.

Free help in North Carolina

Medicare and Medicaid in North Carolina

Medicare counseling
Seniors' Health Insurance Information Program (SHIIP), North Carolina Department of Insurance · 855-408-1212 . Free help with Medicare appeals.
Medicaid agency
NC Medicaid, North Carolina Department of Health and Human Services
Fair hearing deadline
If a Medicaid managed care plan denied care: 120 days from the date the plan's Notice of Resolution (its appeal decision) was mailed. For appeals against the Department of Health and Human Services itself: 30 days from the date the decision was mailed. Your notice states the deadline that applies to you.
Good to know
In Medicaid managed care you must first appeal to your health plan within 60 days of its denial notice (the plan decides within 30 days); only then can you ask the Office of Administrative Hearings for a state fair hearing. Return the State Fair Hearing Request Form that comes with the plan's decision to both the Office of Administrative Hearings and the plan. Hearings office: 984-236-1850, 1711 New Hope Church Road, Raleigh NC 27609.

Medicaid appeals page How Medicaid appeals work

State laws that can help

  • External review. You can ask the Commissioner of Insurance for a free external review by an independent review organization within 120 days of your insurer's final decision, and you get seven days to send the reviewer more information.

    North Carolina General Statutes section 58-50-80 (standard external review)

  • Denial notice. A notice that your insurer refused to certify care must give all reasons including the clinical rationale, tell you how to appeal and how to request the clinical review criteria, and give contact information for Health Insurance Smart NC.

    North Carolina General Statutes section 58-50-61(h)

  • Prior authorization. For prior authorization and ongoing-care reviews, the insurer must communicate its decision within three business days after it has all the necessary information, and a written appeal decision is due within 30 days (expedited appeals within four days).

    North Carolina General Statutes section 58-50-61(f), (j) to (l)

  • Step therapy. Your insurer must have a published exception process for step therapy and drug restrictions and must grant it if your prescriber shows you already tried the other drug, it was ineffective, or it is expected to cause harm, deciding within 72 hours (24 hours if urgent).

    North Carolina General Statutes section 58-3-221(b1) to (b3)

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. NC Department of Insurance: Health Claim Denied? (Smart NC)
  2. NC Department of Insurance: Request an External Review
  3. NC Department of Insurance: External Review Request Form (online)
  4. NC Department of Insurance: Model Evidence of Coverage language for external review
  5. NC Department of Insurance: Request Assistance or File a Complaint
  6. NC Department of Insurance: Medical Appeals
  7. NC Department of Insurance: Seniors' Health Insurance Information Program
  8. North Carolina General Statutes section 58-50-80
  9. North Carolina General Statutes section 58-50-61
  10. North Carolina General Statutes section 58-3-221
  11. North Carolina Office of Administrative Hearings: Filing a Contested Medicaid Recipient Appeal
  12. North Carolina Office of Administrative Hearings: Medicaid Recipient Appeals
  13. North Carolina Justice Center: Your Rights Under NC Medicaid Managed Care
  14. Legal Aid of North Carolina
  15. Centers for Medicare & Medicaid Services: North Carolina Consumer Assistance
  16. State Health Insurance Assistance Programs: North Carolina
Not confirmed (14)
  • How to tell whether the state regulates your plan. the Department of Insurance pages give no insurance-card tip; they say only that external review does not apply to self-funded employer plans, and Smart NC's page says to confirm plan type with your plan documents or insurer.
  • The independent review request form. the online standard-request form was seen in search results and describes itself as standard-only; its link on the external review page was not clicked through. The paper form address (https://www.ncdoi.gov/documents/files/external-review-print-and-mail-or-fax-form) is a relative link given on the page and was not opened. A fax number (919-807-6865) appears only in the model coverage language, not on the live external review page, so it is omitted.
  • How long a fast independent review takes. from the Department's page: Smart NC answers within 3 business days and the reviewer within 4 business days of the request. The statute text for the expedited section (58-50-85 and related) was not read.
  • Published results of independent review. no North Carolina external review overturn statistics were found on the Department's pages, so null.
  • A searchable list of past decisions. no searchable database of past decisions was found.
  • The state regulators. 855-408-1212 is printed as the toll-free line; Agent Services (919-807-6800) is not health-specific. Hours and email were not listed on the Smart NC page.
  • The state regulators. the State Health Plan statement comes from the external review page; the Department does not otherwise regulate the State Health Plan (a State Health Plan board memo says so), which is a separate issue for appeals other than medical necessity.
  • Free consumer help programs. the Smart NC page lists a complaint route for self-insured health plans but does not describe the steps or the agency (likely the U.S. Department of Labor); not verified.
  • Free consumer help programs. Legal Aid of North Carolina's page lists 'health care' as a practice area but does not mention insurance denials, Medicaid or Medicare specifically, and states no income limits.
  • The state Medicaid agency. the specific division name (for example Division of Health Benefits) was not confirmed on an official page; the NC Medicaid website page on appeals returned an error.
  • Notes on Medicaid appeals. the 60-day plan appeal and 30-day plan decision come from a 2022 North Carolina Justice Center guide and Medicaid health plan pages, not an NC Medicaid page; the deadline to keep benefits during an appeal was not found (plans say to check the notice).
  • The Medicaid fair hearing deadline. the 30-day figure for appeals against the Department of Health and Human Services and the 120-day managed care figure come from the Office of Administrative Hearings filing page.
  • State laws that help. statute text was read for sections 58-50-61, 58-50-80 and 58-3-221 through the legislature's website or search extracts; the effective dates of the most recent amendments were not checked. No North Carolina surprise billing, mental health parity, gold card or artificial intelligence statute was researched; a 2025 bill (House Bill 434) that would bar using artificial intelligence as the sole basis for denials was seen only on a bill-tracking site with an unclear status, so it is not listed.
  • Not confirmed. stateLaws (prior-authorization) — section 58-50-61 sets a three business day deadline for decisions on prior authorization; it was read in a search extract of the statute page and not cross-checked with the Department.

Sources last checked . Found a mistake? Report it.