§ 58-3-223. Managed care access to specialist care. - North Carolina Statutes

§ 58‑3‑223. Managed care access to specialist care.

(a)        Each insureroffering a health benefit plan that does not allow direct access to all in‑planspecialists shall develop and maintain written policies and procedures by whichan insured may receive an extended or standing referral to an in‑planspecialist. The insurer shall provide for an extended or standing referral to aspecialist if the insured has a serious or chronic degenerative, disabling, orlife‑threatening disease or condition, which in the opinion of theinsured's primary care physician, in consultation with the specialist, requiresongoing specialty care. The extended or standing referral shall be for a periodnot to exceed 12 months and shall be made under a treatment plan coordinatedwith the insurer in consultation with the primary care physician, thespecialist, and the insured or the insured's designee.

(b)        As used in thissection:

(1)        "Health benefitplan" has the meaning applied in G.S. 58‑3‑167.

(2)        "Insurer"has the meaning applied in G.S. 58‑3‑167.

(3)        "Serious orchronic degenerative, disabling, or life‑threatening disease orcondition" means a disease or condition, which in the opinion of thepatient's treating primary care physician and specialist, requires frequent andperiodic monitoring and consultation with the specialist on an ongoing basis.

(4)        "Specialist"includes a subspecialist. (1999‑168, s. 1; 2001‑446, s. 1.2.)