NEWS RELEASE
Pearl W. Stanley
Extension Agent
Family and Consumer Sciences, CFCS
Bolivia, NC 28422
September 2002
If you have had medical services denied by your insurance company, the North Carolina Department of Insurance has a new division, the Healthcare Review Program, that may be able to help. Last fall, new laws were passed that provide North Carolina insurance consumers with another option to resolve certain coverage disputes with insurance companies. This service is external review and is provided at no cost to the consumer. Denied medical services eligible for external review result from decisions the insurance company makes on the basis that the services are not medically necessary. Some services denied because of cosmetic or experimental exclusions may be eligible for external review if the denial decision was reached after the patient's specific medical condition was considered by the insurer and the service was considered to be cosmetic or experimental for that specific condition. In most cases, the insurance company's appeal process must be exhausted before a request for an external review can be made. External review is an additional process that allows someone who is not satisfied with the outcome of the insurance company's appeal process to ask for an independent medical review of the denial.
The Healthcare Review Program contracts with organizations known as Independent Review Organizations (IROs) that are made up of medical professionals. This assures that a medical professional with the same or very similar knowledge and experience as the treating physician reviews the request. If the independent medical professional decides that the insurance company was wrong in denying the service, the insurance company is required to provide coverage and payment for that service. The consumer and the insurance company are bound by the decision that is made.
Some insurance denial decisions not eligible for external review include those based on clearly stated exclusions, out of network services or benefit limitations. Other types of insurance may not be eligible for external review because they are not considered health benefit plans or are regulated by laws other than North Carolina State law. These include Medicare, Medicare managed care, Medicaid and self-funded employer plans. Other insurance types such as dental, vision, Medicare supplements, long-term care, Workers Compensation and automobile insurance are not considered "health benefit plans."
To be eligible for standard external review a request must meet the following requirements. First, the request must be made to the Healthcare Review Program within 60 days of the date of receiving the final denial letter from the insurance company's highest level of appeal. Second, the request must relate to a denial that was made on the grounds that the service was not medically necessary. Third, the patient must have been covered under a policy with the insurance company at the time the services were requested. Finally, the requested service must reasonably appear to be a covered benefit. The independent reviewer cannot decide that a service must be covered if the insurance policy clearly states that the service is not a covered benefit. Once a request is accepted for external review, a decision can be expected within 45 days from the day the request was made.
An expedited external review is available to review denials at any level for situations where the medical circumstances of the patient may warrant an immediate decision. After the consumer requests an immediate appeal with the insurance company a request may also be made to the Healthcare Review Program for an expedited external review. The Healthcare Review Program's medical consultant determines if the medical circumstances warrant the expedited handling of a request. Specifically, the medical consultant will render an opinion on whether the patient's life, health or ability to regain maximum function will be seriously jeopardized if the patient is required to wait the "standard" time frame of 45 days or the time frame required for the insurance company to make a decision through the internal appeal process. If a request is accepted to be processed on an expedited basis, a decision will be made by the independent reviewer within four days from the day the request was made to the Program.
"It is important to consider all options after being denied medical coverage from your health insurance company," says Insurance Commissioner Jim Long. "The Healthcare Review Program gives consumers another option when appealing their insurance company's decision."
To obtain information about the Healthcare Review Program External Review, visit the North Carolina Department of Insurance web site at www.ncdoi.com. To request an external review call (919) 715-1163 or in North Carolina toll-free at 1-877-885-0231.
(The Seniors' Consumer Column is written monthly by the SHIIP staff. The column is a service of SHIIP, which is a division of the North Carolina Department of Insurance -- Jim Long, Commissioner, P. O. Box 26387, Raleigh, NC 27611; 1-800-443-9354, (919) 733-0111; www.ncshiip.com.)
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Date Created 10/7/2002