§ 58-50-77. Notice of right to external review. - North Carolina Statutes

§ 58‑50‑77. Notice of right to external review.

(a)        An insurer shallnotify the covered person in writing of the covered person's right to requestan external review and include the appropriate statements and information setforth in this section at the time the insurer sends written notice of:

(1)        A noncertificationdecision under G.S. 58‑50‑61;

(2)        An appeal decisionunder G.S. 58‑50‑61 upholding a noncertification; and

(3)        A second‑levelgrievance review decision under G.S. 58‑50‑62 upholding the originalnoncertification.

(b)        The insurer shallinclude in the notice required under subsection (a) of this section for anotice related to a noncertification decision under G.S. 58‑50‑61,a statement informing the covered person that if the covered person has amedical condition where the time frame for completion of an expedited review ofan appeal decision involving a noncertification decision under G.S. 58‑50‑61would reasonably be expected to seriously jeopardize the life or health of thecovered person or jeopardize the covered person's ability to regain maximumfunction, then the covered person may file a request for an expedited externalreview under G.S. 58‑50‑82 at the same time the covered personfiles a request for an expedited review of an appeal involving anoncertification decision under G.S. 58‑50‑61, but that theCommissioner will determine whether the covered person shall be required tocomplete the expedited review of the grievance before conducting the expeditedexternal review.

(c)        The insurer shallinclude in the notice required under subsection (a) of this section for anotice related to an appeal decision under G.S. 58‑50‑61, astatement informing the covered person that:

(1)        If the coveredperson has a medical condition where the time frame for completion of anexpedited review of a grievance involving an appeal decision under G.S. 58‑50‑61would reasonably be expected to seriously jeopardize the life or health of thecovered person or jeopardize the covered person's ability to regain maximumfunction, the covered person may file a request for an expedited externalreview under G.S. 58‑50‑82 at the same time the covered personfiles a request for an expedited review of a grievance involving an appealdecision under G.S. 58‑50‑62, but that the Commissioner willdetermine whether the covered person shall be required to complete theexpedited review of the grievance before conducting the expedited externalreview.

(2)        If the coveredperson has not received a written decision from the insurer within 60 daysafter the date the covered person files the second‑ level grievance withthe insurer pursuant to G.S. 58‑50‑62 and the covered person hasnot requested or agreed to a delay, the covered person may file a request forexternal review under G.S. 58‑50‑80 and shall be considered to haveexhausted the insurer's internal grievance process for purposes of G.S. 58‑50‑79.

(d)        The insurer shallinclude in the notice required under subsection (a) of this section for anotice related to a final second‑level grievance review decision underG.S. 58‑50‑62, a statement informing the covered person that:

(1)        If the coveredperson has a medical condition where the time frame for completion of astandard external review under G.S. 58‑50‑80 would reasonably beexpected to seriously jeopardize the life or health of the covered person orjeopardize the covered person's ability to regain maximum function, the coveredperson may file a request for an expedited external review under G.S. 58‑50‑82;or

(2)        If the second‑levelgrievance review decision concerns an admission, availability of care,continued stay, or health care service for which the covered person receivedemergency services but has not been discharged from a facility, the coveredperson may request an expedited external review under G.S. 58‑50‑82.

(e)        In addition to theinformation to be provided under this section, the insurer shall include a copyof the description of both the standard and expedited external reviewprocedures the insurer is required to provide under G.S. 58‑50‑93,including the provisions in the external review procedures that give thecovered person the opportunity to submit additional information. (2001‑446, s. 4.5.)