North Carolina General Statutes 108D-11. Managed care entity grievance and appeal procedures, generally
(a) Each managed care entity shall establish and maintain internal grievance and appeal procedures that (i) comply with the Social Security Act and 42 C.F.R. part 438, Subpart F, and (ii) afford enrollees and their authorized representatives constitutional rights to due process and a fair hearing.
(b) An enrollee, or the enrollee’s authorized representative, may file grievances and managed care entity level appeals orally or in writing.
(c) A managed care entity shall not attempt to influence, limit, or interfere with an enrollee’s right or decision to file a grievance, request for a managed care entity level appeal, or a contested case hearing. However, nothing in this Chapter shall be construed to prevent a managed care entity from doing any of the following:
(1) Offering an enrollee alternative services.
Terms Used In North Carolina General Statutes 108D-11
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- following: when used by way of reference to any section of a statute, shall be construed to mean the section next preceding or next following that in which such reference is made; unless when some other section is expressly designated in such reference. See North Carolina General Statutes 12-3
- in writing: may be construed to include printing, engraving, lithographing, and any other mode of representing words and letters: Provided, that in all cases where a written signature is required by law, the same shall be in a proper handwriting, or in a proper mark. See North Carolina General Statutes 12-3
- state: when applied to the different parts of the United States, shall be construed to extend to and include the District of Columbia and the several territories, so called; and the words "United States" shall be construed to include the said district and territories and all dependencies. See North Carolina General Statutes 12-3
(2) Engaging in clinical or educational discussions with enrollees or providers.
(3) Engaging in informal attempts to resolve enrollee concerns prior to the issuance of a notice of grievance disposition or notice of resolution.
(d) A managed care entity shall not take punitive action against a provider for any of the following:
(1) Filing a grievance on behalf of an enrollee or supporting an enrollee’s grievance.
(2) Requesting a managed care entity level appeal on behalf of an enrollee or supporting an enrollee’s request for a managed care entity level appeal.
(3) Requesting an expedited managed care entity level appeal on behalf of an enrollee or supporting an enrollee’s request for a managed care entity level expedited appeal.
(4) Requesting a contested case hearing on behalf of an enrollee or supporting an enrollee’s request for a contested case hearing.
(e) The appeal procedures set forth in this Article shall not apply to instances in which the sole basis for the managed care entity’s decision is a provision in the State Plan or in federal or State law requiring an automatic change adversely affecting some or all beneficiaries. (2013-397, s. 1; 2019-81, s. 1(a); 2021-62, s. 2.1(f).)