Health insurance or Medicaid said no in North Carolina? Deadlines and free help

In North Carolina, your health plan is regulated by North Carolina Department of Insurance (NCDOI), if it is a state-regulated plan.

North Carolina runs its own independent review of denials: External Review (Health Insurance Smart NC). You generally have 120 days to ask for it.

External review means a doctor or reviewer outside your plan decides again. Internal appeal means your plan looks at its own decision again.

Pick your plan type

Which kind of coverage was denied? The plan type decides which rules and deadlines apply.

Insurance I bought or got through work

Your state insurance rules may apply. First appeal to your plan, then ask for an outside review.

My employer pays claims itself (self-funded)

Federal rules apply, and most state insurance laws do not. Free help comes from the U.S. Department of Labor.

NC Medicaid

You ask the state for a fair hearing. In a Medicaid health plan, you usually appeal to the plan first.

Marketplace (HealthCare.gov) decision

A decision about whether you can buy a plan or get financial help is appealed to the Marketplace.

How long do I have?Urgent care: faster decisionWrite my appealFree help

Checked against official sources: October 30, 2026.

Appeal deadlines are strict. If you are near a deadline or your care is urgent, call free help today.

How long do I have in North Carolina?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
120 days
Hearing deadline
30 days for services, 60 days for eligibility
Appeal to the plan first
60 days (federal rule)
Then a state hearing
120 days
Appeal deadline – HealthCare.gov
90 days (federal rule)

All the details →

How long do I have? Deadline calculator

How do I know which plan type I have?

How to tell which agency regulates your plan

North Carolina's external review does not apply to self-funded employer health plans (where the employer pays claims from its own funds, often through an insurance company as administrator), Medicare or Medicaid. For self-funded job-based plans, contact the U.S. Department of Labor's Employee Benefits Security Administration.

Step 1: Appeal to your plan in North Carolina

What it is called: Appeal and second-level grievance

North Carolina insurers have an appeal of a denial (noncertification) and, for some plans, a second-level grievance review. If you filed a second-level grievance and get no written decision within 60 days (unless you agreed to a delay), you are treated as having finished the insurer's process and can ask for external review. Health Insurance Smart NC (1-855-408-1212) helps consumers with appeals.

Law: N.C. Gen. Stat. 58-50-61, 58-50-62, 58-50-79(b)

All the details →

Step 2: Outside review in North Carolina

External Review (Health Insurance Smart NC)

Deadline to ask: 120 days.

All the details →

Urgent care in North Carolina: faster decisions

Outside review

Expedited review is available if the time for a standard decision could seriously jeopardize your life or health or your ability to regain maximum function. The reviewer must decide within 3 days after the request is received (Smart NC says you will hear within 4 business days of your request). Your provider must sign the Physician Certification Form (Attachment A). Not available for care already received.

Law: N.C. Gen. Stat. 58-50-75, 58-50-79, 58-50-80, 58-50-82, 58-50-84, 58-50-92

Urgent: 3 days

Complaints about your plan in North Carolina

For other problems with an insurer, use the NCDOI online assistance or complaint request form, or call 1-855-408-1212. Mailing address: N.C. Department of Insurance, 1201 Mail Service Center, Raleigh, NC 27699.

my.ncdoi.com

Medicaid (NC Medicaid (including NC Medicaid Managed Care)) denials in North Carolina

Who holds the hearing: N.C. Office of Administrative Hearings (service denials); county department of social services and NCDHHS (eligibility).

Hearing deadline: 30 days for services, 60 days for eligibility

All the details →

Marketplace decisions in North Carolina

North Carolina uses HealthCare.gov. Appeals go to the federal Marketplace Appeals Center.

HealthCare.gov

1-855-231-1751

Other rights in North Carolina

State Health Plan

Medical necessity decisions by the North Carolina State Health Plan for Teachers and State Employees can also go to state external review.

Law: N.C. Gen. Stat. 58-50-75(b)

How long do I have? Deadline calculator

Pick your plan type and enter the dates on your notice. We count from the rules in North Carolina and the federal rules.

Worked out in your browser. Nothing you enter here is saved or sent.

If you are not sure when it arrived, use the date printed on the notice. That date is never later than the day it arrived.

Choose what was decided and enter the date on your notice

We add the number of days or months from the law to your date. Nothing is saved.

Write my appeal: free letters

Free help in North Carolina

Good to know in North Carolina

  • North Carolina's external review covers the State Health Plan for Teachers and State Employees.

    Law: N.C. Gen. Stat. 58-50-75(b)

  • NC Medicaid service denials outside managed care must be appealed to the Office of Administrative Hearings within 30 days of mailing; eligibility appeals go to the county within 60 days.

    Law: N.C. Gen. Stat. 108A-70.9A; N.C. Gen. Stat. 108A-79

  • NC Medicaid health plans must presume an expedited appeal is needed when a network provider asks for it.

    Law: N.C. Gen. Stat. 108D-14(a)

Questions about appeals in North Carolina

How long do I have to appeal a health insurance denial in North Carolina?

Use the deadline on your denial notice. Federal rules give at least 180 days for most plans. You have at least 180 days (about 6 months) from when you receive the denial notice to file an internal appeal.

How do I get an outside (external) review in North Carolina?

External Review (Health Insurance Smart NC). For a standard review, use the online External Review Request Form or the print-and-mail-or-fax form. For an expedited review, use the print-and-mail-or-fax form with the Physician Certification Form signed by your provider.

Is outside review free in North Carolina?

External review is free. The insurer pays the review organization's fees.

How long do I have to ask for a Medicaid fair hearing in North Carolina?

30 days for services, 60 days for eligibility. The date the notice was mailed, for a service denial by NC Medicaid outside a health plan (file with the Office of Administrative Hearings).

Can I keep my Medicaid benefits while I appeal in North Carolina?

For eligibility, your Medicaid continues at the same level until the local hearing decision if you request a hearing on or before the date the termination or change takes effect. For service cuts by NC Medicaid, services continue until the hearing decision if you request a hearing before the effective date of the decision.

Who regulates health insurance in North Carolina?

North Carolina Department of Insurance (NCDOI). North Carolina's external review does not apply to self-funded employer health plans (where the employer pays claims from its own funds, often through an insurance company as administrator), Medicare or Medicaid. For self-funded job-based plans, contact the U.S. Department of Labor's Employee Benefits Security Administration.

Not about a denied claim?

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