What is a Medical Appeal?
An appeal is another review of your case by your insurance company. Appeals must be made in writing. Your insurance company will notify you of your appeal rights when you receive your notice of denial. Smart NC can review your adverse benefit determination notice with you, discuss your rights under North Carolina law and assist you with the appeal process.
You can appeal a noncertifications decision (medical necessity denial), but not a decision to deny coverage because the specific healthcare services are clearly excluded under the terms of your health insurance policy. Your policy should clearly list services that are excluded from coverage.
The Smart NC program is happy to review your denial and discuss what options are available to you. Please contact the Smart NC program at 855-408-1212 or you can complete and submit a Request for Assistance form along with the items on the Medical Appeal Checklist. We look forward to assisting you with your health insurance issues and concerns.