§ 135-44.7. Administrative review. - North Carolina Statutes

§ 135‑44.7. Administrative review.

(a)        If, afterexhaustion of internal appeal handling as outlined in the contract with theClaims Processor any person is aggrieved, the Claims Processor shall bring thematter to the attention of the Executive Administrator and Board of Trustees,which shall promptly decide whether the subject matter of the appeal is adetermination subject to external review under Part 4 of Article 50 of Chapter58 of the General Statutes. The Executive Administrator and Board of Trusteesshall inform the aggrieved person and the aggrieved person's provider of thedecision and shall provide the aggrieved person notice of the aggrievedperson's right to appeal that decision as provided in this subsection. If theExecutive Administrator and Board of Trustees decide that the subject matter ofthe appeal is not a determination subject to external review, then theExecutive Administrator and Board of Trustees may make a binding decision onthe matter in accordance with procedures established by the ExecutiveAdministrator and Board of Trustees. The Executive Administrator and Board ofTrustees shall provide a written summary of the decisions made pursuant to thissection to all employing units, all health benefit representatives, theoversight team provided for in G.S. 135‑43.3, all relevant health careproviders affected by a decision, and to any other parties requesting a writtensummary and approved by the Executive Administrator and Board of Trustees toreceive a summary immediately following the issuance of a decision. A decisionby the Executive Administrator and Board of Trustees that a matter raised oninternal appeal is a determination subject to external review as provided insubsection (b) of this section may be contested by the aggrieved person underChapter 150B of the General Statutes. The person contesting the decision mayproceed with external review pending a decision in the contested case underChapter 150B of the General Statutes.

(b)        The ExecutiveAdministrator and Board of Trustees shall adopt and implement utilizationreview and internal grievance procedures that are substantially equivalent tothose required under G.S. 58‑50‑61 and G.S. 58‑50‑62.External review of determinations shall be conducted in accordance with Part 4of Article 50 of Chapter 58 of the General Statutes. As used in this section,"determination" is a decision by the Executive Administrator andBoard of Trustees, or the Plan's designated utilization review organizationadministrated by or under contract with the Plan that an admission,availability of care, continued stay, or other health care service has beenreviewed and, based upon information provided, does not meet the Plan'srequirements for medical necessity, appropriateness, health care setting, or levelof care or effectiveness, and the requested service is therefore denied,reduced, or terminated.

(c)        The Board ofTrustees shall make the final agency decision in all cases contested pursuantto Chapter 150B of the General Statutes. The Executive Administrator shallexecute the Board's final agency decisions. For purposes of G.S. 150B‑44,the Board of Trustees is an agency that is a board or commission.  (1981 (Reg. Sess., 1982), c.1398, s. 6; 1985, c. 732, s. 53; 1985 (Reg. Sess., 1986), c. 1020, s. 20; 1991,c. 427, s. 6; 2001‑446, s. 5(e); 2008‑168, ss. 1(a), 2(a), (n).)