North Carolina General Statutes 58-50-79. Exhaustion of internal grievance process
(a) Except as provided in N.C. Gen. Stat. § 58-50-82, a request for an external review under N.C. Gen. Stat. § 58-50-80 or N.C. Gen. Stat. § 58-50-82 shall not be made until the covered person has exhausted the insurer’s internal appeal and grievance processes under N.C. Gen. Stat. § 58-50-61 and N.C. Gen. Stat. § 58-50-62.
(b) A covered person shall be considered to have exhausted the insurer’s internal grievance process for purposes of this section, if the covered person:
(1) Has filed a second-level grievance involving a noncertification appeal decision under N.C. Gen. Stat. § 58-50-61 and N.C. Gen. Stat. § 58-50-62, and
Terms Used In North Carolina General Statutes 58-50-79
- 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.
- 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
(2) Except to the extent the covered person requested or agreed to a delay, has not received a written decision on the grievance from the insurer within 60 days since the date the covered person can demonstrate that a grievance was filed with the insurer.
(c) Notwithstanding subsection (b) of this section, a covered person may not make a request for an external review of a noncertification involving a retrospective review determination made under N.C. Gen. Stat. § 58-50-61 until the covered person has exhausted the insurer’s internal grievance process.
(d) A request for an external review of a noncertification may be made before the covered person has exhausted the insurer’s internal grievance and appeal procedures under N.C. Gen. Stat. § 58-50-61 and N.C. Gen. Stat. § 58-50-62 whenever the insurer agrees to waive the exhaustion requirement. If the requirement to exhaust the insurer’s internal grievance procedures is waived, the covered person may file a request in writing for a standard external review as set forth in N.C. Gen. Stat. § 58-50-80 or may make a request for an expedited external review as set forth in N.C. Gen. Stat. § 58-50-82. In addition, the insurer may choose to eliminate the second-level grievance review under N.C. Gen. Stat. § 58-50-62. In such case, the covered person may file a request in writing for a standard external review under N.C. Gen. Stat. § 58-50-80 or may make a request for an expedited external review as set forth in N.C. Gen. Stat. § 58-50-82 within 60 days after receiving notice of an appeal decision upholding a noncertification. (2001-446, s. 4.5; 2009-382, s. 25.)