When can I request an external review?

External review is available whether you have already received a service and coverage for it has been denied or you have requested and been denied coverage for a service that you have not yet received.

Most people will qualify for a standard external review, which results in a decision within 45 days of submitting a request for review. An expedited external review, under which a decision is made within three days of submitting a request, is available in cases where the time involved in obtaining a final decision can have an impact on a person's health. The specific eligibility requirements for expedited review and a detailed description of the standard and expedited review processes are explained in the next several questions and answers.

After I request an external review, when should I expect to hear something?

For standard review:

Within 10 business days after requesting external review, you will receive notification whether the request is complete and whether it has been accepted for review.

If the request is incomplete, Smart NC will ask you to provide the required information within 150 days of the date you received your final determination from your health plan. If Smart NC does not receive the information within this time frame, your request will be considered ineligible and you will not be able to request a review for that specific service again.

If your request is complete Smart NC will advise you of whether your case has been accepted for external review. If accepted, you will be provided with the name of the Independent Review Organization (IRO) assigned to the case and given a copy of the information that was provided to Smart NC by your health insurer. You will also be notified at that time that you have seven days in which to provide the IRO any additional information that you feel would help the IRO make a determination. You may submit this information directly to the IRO or send it to Smart NC for timely forwarding to the IRO. If you choose to submit additional information directly to the IRO, you must also provide the same information to your health insurer at the same time and by the same means. (For example, if you are faxing information to the IRO, you must also fax information to your health insurer.)

If you do submit additional information, your health insurer will have the opportunity to consider the information and, if it chooses, reverse its own denial. If this does occur, the insurer will inform you and the IRO of this decision and the IRO will stop the external review. However, this "reconsideration " process will not slow down the external review and will not affect it if your insurer does not change its decision as a result of the new information.

Upon making its decision, the IRO will notify you in writing of its decision. This will be no more than 45 days after Smart NC received your request.

For an expedited review:

Within three business days after you make your request, Smart NC will notify you whether your request meets the criteria for an expedited review. This decision will be made in consultation with a medical professional. If your request was accepted, you will be given the name of the IRO assigned to your case.

You will receive verbal or written notification of the IRO's decision within four business days of making your request to Smart NC. If you receive a verbal notification from the IRO, you will receive a written notification of their decision within two days of their verbal notification.

If your request was not accepted for external review, you will be notified by Smart NC that:

• you must first complete your health insurer's appeal process (or expedited appeal process) before the request is eligible for external review; or
• your request is accepted for standard rather than expedited external review; or
• your request is not eligible for external review of any kind.

What documents should I provide that will help the IRO make a determination?

You have an opportunity to provide the Independent Review Organization (IRO) any additional information that you think helps makes the case that the services that were denied were medically necessary. Examples of these documents might include:

• your doctor's or healthcare provider's recommendation that the services that were denied to you were medically necessary;
• any medical information or justification that your denied service was or is medically necessary; or
• any other information that supports your position that the services denied to you were or are medically necessary.

What happens when an external reviewer makes a decision?

The Independent Review Organization (IRO) notifies you, your healthcare provider, Smart NC, and your health insurer when it makes a decision on your request. If the IRO's decision overturns your health insurer's original decision, the health plan must provide for coverage or payment within three days for a standard external review request and within one day for an expedited external review request. This decision is binding on you and your health plan. If the IRO's decision is to agree with your health insurer's original decision, you may not request another review on this case. The decision is binding on you and your insurer except to the extent you may have other remedies available under applicable federal or state law.

Who conducts the external review?

The external review is conducted by an organization called an Independent Review Organization (IRO). IROs are contracted with Smart NC to perform impartial reviews of your case to determine the merits of your request and to determine if your request should be covered under your policy. The doctors or medical professionals who review your request are Board Certified Specialists and have the same or similar background as the doctors or medical professionals who provided or requested your care. They will review your insurance coverage policy, as well as the medical documents and other information supplied to them by you and your insurer for review. Your request will be considered against the standard of practice in the medical community. IRO decisions will be made based upon supporting clinical evidence, standards of practice and personal experience of the specialty reviewer.

Can I request a review for any type of insurance denial?

External review is available for most health insurers that make coverage decisions based on medical necessity. Other types of denial decisions are not eligible for external review.

Medical necessity decisions made by North Carolina State Health Plan are also subject to external review.

North Carolina's state external review does not apply to self-funded employer health plans. (These are health plans for which an employer sets aside his own funds to pay for health claims rather than purchasing insurance, and are often "administered" by health insurance companies.) External review also does not apply to Medicare or Medicaid and is not available for certain types of insurance, including: dental, vision, Medicare supplement, long-term care, specified disease, workers compensation, credit, or disability income, or to medical payments under homeowners or auto insurance.

What are the eligibility requirements to request an external review?

In order for your request to be eligible for external review, Smart NC must determine that all of the following criteria have been met:

1. Your request was submitted within 120 days of receiving your insurer's final decision on appeal or, for expedited external review, within 120 days of receiving either the initial denial or decision on appeal. (See questions # 5 and 6 for additional discussion of time allowed to request external review.) (Eff. 10/1/09)
2. Your request relates to a type of health insurance coverage that is subject to external review. (See question #3 for information on the types of insurance that is subject to external review.)
3. Your request is about an insurer's medical necessity determination that resulted in a denial (noncertification) decision. (See question #2 for information on noncertifications.)
4. You had coverage in effect with the insurer at the time the services were requested or provided and the denial decision was issued.
5. The service for which coverage was denied appears to be a covered benefit under the health insurance policy.
6. That you have exhausted your insurer's appeals process as described in question #5 above OR, if you are requesting expedited external review, that you meet the medical criteria for expedited review and requested an expedited appeal with your insurer as described in question #6.

Must I request an external review myself?

No. You may designate any person you wish, including your health care provider, as your Authorized Representative to act on your behalf in pursuing an external review. The Request for External Review Form includes a section on contact information for an authorized representative. Be sure that this information is included if someone will be acting as your representative. Smart NC staff cannot be your authorized representative.

In the case of a minor or someone deemed incompetent, a request must be made by a parent, conservator, guardian, health care power-of-attorney or any individual who has been designated as the patient's authorized representative.