External review in North Carolina: deadline, cost and how to ask
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.
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.
Step 2: Outside review in North Carolina
- Program
External Review (Health Insurance Smart NC)
- Who runs it
- N.C. Department of Insurance, Health Insurance Smart NC (assigns an independent review organization): Insured health plans in North Carolina and the State Health Plan for Teachers and State Employees
- Deadline to ask
120 days
File within 120 days after you receive the notice of the insurer's final decision. If Smart NC asks for missing information, it must be received within 150 days after the date of the insurer's decision. The reviewer decides a standard review within 45 days after Smart NC receives the request.
- The deadline runs from
The date you receive the insurer's final appeal or grievance decision (for expedited review, the initial denial or the appeal decision)
- Do I have to appeal to my plan first?
You must finish the insurer's appeal and grievance process first, unless the insurer waives it or does not decide your second-level grievance within 60 days. For expedited review, you can apply when you ask the insurer for an expedited appeal if your condition is urgent.
- When you can go without a plan answer
60 days after you file your internal appeal
- How long the review takes
Urgent: 3 days
- Cost
External review is free. The insurer pays the review organization's fees.
- What can be reviewed
Denials based on medical necessity (noncertifications) of a service that appears to be a covered benefit, whether you already received the care or not. Other types of denials are not eligible. Not covered: self-funded employer plans, Medicare, Medicaid, dental, vision, Medicare supplement, long-term care, specified disease, workers' compensation, credit or disability income coverage.
- Is the decision final?
The decision is binding on the insurer, and on you except where you have other remedies under federal or state law. If the reviewer overturns the denial, the plan must provide coverage or payment within 3 days (1 day for expedited). You cannot ask for another review of the same case.
- How to ask
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. You get 7 days after the reviewer is assigned to send more information. You can name an authorized representative, including your provider.
Law: N.C. Gen. Stat. 58-50-75, 58-50-79, 58-50-80, 58-50-82, 58-50-84, 58-50-92
- Forms and online request
- Phone
Write my appeal: free letters
Sources
The official sources for North Carolina are listed on the North Carolina page.