§ 58-50-75. Purpose, scope, and definitions. - North Carolina Statutes

Part 4. Health Benefit PlanExternal Review.

§ 58‑50‑75. Purpose, scope, and definitions.

(a)        The purpose of thisPart is to provide standards for the establishment and maintenance of externalreview procedures to assure that covered persons have the opportunity for anindependent review of an appeal decision upholding a noncertification or asecond‑level grievance review decision upholding a noncertification, asdefined in this Part.

(b)        This Part appliesto all insurers that offer a health benefit plan and that provide or performutilization review pursuant to G.S. 58‑50‑61, the State Health Planfor Teachers and State Employees, any optional plans or programs operatingunder Part 2 of Article 3A of Chapter 135 of the General Statutes, the NorthCarolina Health Insurance Risk Pool, and the Health Insurance Program forChildren. With respect to second‑level grievance review decisions, thisPart applies only to second‑level grievance review decisions involvingnoncertification decisions.

(c)        In addition to thedefinitions in G.S. 58‑50‑61(a), as used in this Part:

(1)        "Coveredbenefits" or "benefits" means those benefits consisting ofmedical care, provided directly through insurance or otherwise and includingitems and services paid for as medical care, under the terms of a healthbenefit plan.

(2)        "Coveredperson" means a policyholder, subscriber, enrollee, or other individualcovered by a health benefit plan. "Covered person" includes anotherperson, including the covered person's health care provider, acting on behalfof the covered person. Nothing in this subdivision shall require the coveredperson's health care provider to act on behalf of the covered person.

(3)        "Independentreview organization" or "organization" means an entity thatconducts independent external reviews of appeals of noncertifications andsecond‑level grievance review decisions.  (2001‑446, s. 4.5; 2007‑298, s. 8.5; 2007‑323,s. 28.22A(o); 2007‑345, s. 12; 2009‑382, s. 24.)