North Carolina program
Appeal a denial outside the plan
Smart NC offers a free review of a treatment denial by someone outside the health plan.
What it is
Smart NC offers a free review of a treatment denial by someone outside the health plan.
An independent reviewer can overturn a medical-necessity denial. This state route covers insured plans and the State Health Plan. Private self-funded employer plans use a different route.
Eligibility rules
- A medical-necessity denial and a covered plan are required. Private self-funded employer plans are outside this state process.
What you get
- A free independent decision that binds the plan.
- An urgent review when the required medical certification supports it.
What the help covers
- The review is independent of the insurer. A decision overturning the denial binds the plan.
If you decide to apply
- Ask Smart NC at 855-408-1212 which review route covers the plan.
- Gather the denial, any internal appeal decision and supporting medical records.
- For urgent review, ask the doctor to sign the certification and send it with the request by mail or fax.
An independent review organization appointed by the Department of Insurance: 855-408-1212 · Official page ↗
If you decide to apply
- The request must be made within 120 days after the denial. Standard review takes up to 45 days; the urgent statutory limit is three days.
Good to know
The plan’s own appeal normally comes first, unless that requirement is waived. Urgent review needs the doctor’s certification.
Other details
- The State Health Plan uses the state external-review route and allows 180 days for an internal grievance first.
Official sources
“If treatment is denied, would an outside review fit our plan and situation? Could you help compare it with the plan appeal and gather the medical evidence, especially if treatment cannot wait?”
Why I’m asking: I want a denial checked by someone independent without missing the deadline.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
Send the denial letter and the medical records, and keep the date you filed.
Your social worker
Smart NC staff walk you through the form.
The care team
The oncologist signs the physician certification when it is urgent.
- Who decides
- An independent review organisation the Department of Insurance appoints.
- Ask your social worker
- “Can we file for Smart NC external review today, and ask the oncologist to sign the urgent certification now?”
How to apply
First step: Call Smart NC on 855-408-1212 the day a denial arrives.
- Call Smart NC on 855-408-1212 the day the denial arrives.
- Ask the oncologist to sign the physician certification for the urgent route.
- Ask human resources in writing whether the plan is insured or self-funded.
Official application / program page ↗
Where it starts: Call Smart NC on 855-408-1212. For the urgent route, send the request form and the signed physician certification by post or fax.
What to gather
- The denial letter
- The plan’s appeal decision, if there is one
- Medical records supporting the request
- The signed physician certification for an urgent case
How long: 45 days standard; the statute says not more than three days when urgent.
Clock: You have 120 days from the qualifying denial or final internal appeal to ask for external review.
What a yes looks like
The reviewer overturns the denial and the plan has to pay.
What a no looks like, and the next move
Ask what evidence the reviewer relied on and whether a new request with fresh records is possible.
Watch out
- A self-funded employer plan is outside this route. Ask human resources in writing which yours is.
- The urgent route needs the doctor’s signed certification with the request.
- 120 days from the denial is the outer limit. File early.
The numbers and the rules
The arcane layer, kept on purpose. Checked September 11, 2026.
What it is worth
A free independent review: 120 days to file, 45 days to decide, three days when it is urgent.
- $120 — Days to ask for review after the denial
- $45 — Days for a standard decision
- $3 — Days for an urgent decision under the statute
Legal protection: The reviewer is independent of the plan and the decision binds it · It is free to the family
What it costs the family: No cost.
The eligibility facts, as published
- Plan type
- insured plans and the State Health Plan; private self-funded employer plans are excluded
- Trigger
- a medical-necessity denial, after the plan’s own appeal or where that is waived
The trap: The urgent route needs a physician certification form sent by post or fax with the request. Ask the oncologist to sign it the same day.
Where I read this
- Request an External Review — NC Department of Insurance, read September 10, 2026
- G.S. 58-50-82: Expedited External Review — North Carolina General Assembly, read September 10, 2026
- G.S. 58-3-167: Applicability to Health Benefit Plans — North Carolina General Assembly, read September 10, 2026
- NC General Statutes Chapter 135, Article 3B (State Health Plan) — North Carolina General Assembly, read September 10, 2026
- Appeals Process for Standard and Plus PPO Plans — NC State Health Plan, read September 10, 2026