North Carolina General Statutes 135-48.24. Administrative review
(a) If, after exhaustion of internal appeal handling outlined in the contract with the Claims Processor, any person is aggrieved, then the Claims Processor shall bring the matter to the attention of the Executive Administrator. The Executive Administrator shall promptly decide whether the subject matter of the internal appeal is a determination subject to external review under Part 4 of Article 50 of Chapter 58 of the N.C. Gen. Stat.. The following shall apply to decisions made under this subsection:
(1) The Executive Administrator shall inform the aggrieved person and the aggrieved person’s provider of the decision and shall provide the aggrieved person notice of the aggrieved person’s right to appeal that decision as provided in this subsection.
Terms Used In North Carolina General Statutes 135-48.24
- 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.
- Board of Trustees: shall mean the Board provided for in N. See North Carolina General Statutes 135-1
- Contract: A legal written agreement that becomes binding when signed.
- 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
- Plan: includes all comprehensive health benefit plans offered under the Plan. See North Carolina General Statutes 135-48.1
- Service: shall mean service as a teacher or State employee as described in subdivision (10) or (25) of this section. See North Carolina General Statutes 135-1
- 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) If the Executive Administrator decides that the subject matter raised on internal appeal is not a determination subject to external review, then the Executive Administrator shall have the authority to make a binding decision on the matter.
(3) If the Executive Administrator decides that the subject matter raised on internal appeal is a determination subject to external review, as provided for under subsection (b) of this section, then that decision may be contested by the aggrieved person under Chapter 150B of the N.C. Gen. Stat.. The person contesting the decision may proceed with external review pending a decision in the contested case under Chapter 150B of the N.C. Gen. Stat..
(b) The State Treasurer, in consultation with the Board of Trustees, shall adopt and implement utilization review and internal grievance procedures that are substantially equivalent to those required under N.C. Gen. Stat. § 58-50-61 and N.C. Gen. Stat. § 58-50-62. External review of determinations shall be conducted in accordance with Part 4 of Article 50 of Chapter 58 of the N.C. Gen. Stat.. As used in this section, “determination” is a decision by the State Treasurer, or the Plan‘s designated utilization review organization administrated by or under contract with the Plan that an admission, availability of care, continued stay, or other health care service has been reviewed and, based upon information provided, does not meet the Plan’s benefit offerings, or requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service is therefore denied, reduced, or terminated.
(c) Repealed by Session Laws 2011-398, s. 49, effective January 1, 2012, and applicable to contested cases commenced on or after that date. (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1985, c. 732, s. 53; 1985 (Reg. Sess., 1986), c. 1020, s. 20; 1991, c. 427, s. 6; 2001-446, s. 5(e); 2008-168, ss. 1(a), 2(a), (n); 2011-85, ss. 2.5(g), 2.10; 2011-398, s. 49; 2021-125, s. 3(a).)