North Carolina external review

North Carolina's Smart NC program is one of the few in the country with hands-on staff who will help you prepare the request itself — reviewing your denial notice, helping gather records, and walking you through the process. Reviews are free, decided within 45 days (about 4 business days expedited), and when you win, the insurer must comply within 1–3 business days.

Deadlines and decision timelines

• Your filing window: 120 days from the final internal denial.
• Standard review decided in: 45 days from Smart NC's receipt of the request
• Expedited review decided in: about 4 business days — waiting would seriously jeopardize your life, health, or ability to regain maximum function — or emergency-service denials while you're still hospitalized; internal-appeal exhaustion can be waived
• Cost to you: None

How to file, step by step

1. Call Smart NC before you file. 1-855-408-1212. Staff will review your adverse benefit determination notice, explain your rights under NC law, and help you assemble the request — including a Medical Appeals Checklist and Tool Kit.
2. File within 120 days. Standard requests can go through the online portal (secure1.ncdoi.com) or the External Review Request Form by mail or fax to NCDOI, 1201 Mail Service Center, Raleigh, NC 27699-1201.
3. Expedited requests use the paper form. They require a physician certification of urgency — Smart NC determines eligibility within 2 days and the IRO decides within about 4 business days total.
4. Smart NC screens, the IRO decides. Staff perform the preliminary eligibility review, then assign your case to an independent review organization. Standard decisions arrive within 45 days.

Who can use it

• State-regulated (fully-insured) health plans, for medical-necessity noncertifications — including some cosmetic and experimental denials — where coverage was in effect and the service appears to be a covered benefit.
• Not eligible: self-funded employer (ERISA) plans (ask HR — those use the federal process), Medicare and Medicare supplements, Medicaid, dental/vision, long-term care, workers' comp, and med-pay under home or auto policies.

What to know

• Send medical records and test results with the request — the IRO decides on the record in front of it.
• If the review overturns the denial, the insurer must provide coverage or payment within 3 business days (1 day for expedited reviews).
• The decision is binding on the insurer (G.S. 58-50-84); you keep your other legal remedies.
• NCDOI reported $1.9 million recovered for consumers through Smart NC reviews and appeals in 2025.

Primary sources

• NCDOI — Request an External Review (Smart NC)
• G.S. 58-50-80 — standard external review
• G.S. 58-50-84 — binding effect
• NCDOI — consumer guide to external review (PDF)