APPEAL & GRIEVANCE PROVISIONS

Plan members have two separate appeal routes. One takes place when the member contests a decision to deny or limit health care services (non-certification decision). This is called an appeal.¹ The other appeal route occurs when a member is unhappy with other aspects of the plan’s operations. A complaint about other operations of the plan is called a grievance.

Members have the right to two levels of review, for both appeals and grievances. The first level of review has a different name and a slightly different process depending on whether it is a first-level appeal or first-level grievance review. However, the second-level review is the same regardless of whether the dispute is a denial of services or another problem with the plan’s operation. This is referred to as a second-level grievance hearing.

Members who contest non-certification decisions (denials of services or procedures) have a right to ask for expedited review if the normal time limits could hurt the person’s health. Otherwise the normal time limits apply. There is not an expedited process for first-level grievance decisions, because first-level grievance hearings do not deal with non-certification decisions (these are handled at the first level appeals).

Appeals of Non-Certification Decisions

• Denial Notices: When health plans deny care, they must send the covered member a non-certification letter explaining why the requested service or procedure was denied. The notice must include the clinical reasons for the non-certification as well as instructions on how to appeal the plan’s decision (NCGS 58-50-61(h)). Members should always ask for a copy of the clinical review criteria used in making the decision. This provides a more complete explanation for why the requested treatment, procedure or admission was denied.
  
  
• First Level Appeals: Members can file an appeal on their own behalf. In addition, a physician or other person acting on the member’s behalf can file an appeal (NCGS 58-50-61(j)). All plans must offer at least two levels of appeals. A physician who was not involved in the original decision must hear the first appeal. Normally the physician has 30 days to decide the appeal.
  
  
• Expedited Review: Member can request an expedited appeal if their health would be harmed by the 30-day delay. In an expedited appeal, the physician has up to four days to make a decision. However, members can request the decision be made immediately if there is a more immediate health care need (NCGS 58-50-61(k), (l)). Members will have their health services covered until the member is notified of the expedited review decision, if the appeal involves concurrent review such as continued stay in a hospital. Members are not entitled to expedited review if the health care services have already been provided and the issue is whether the care was appropriate (retrospective review).
  
  
• Notice of Decision: Each health plan or utilization review organization must provide a written decision to the member and the member’s provider. The decision should contain the qualifications of the person reviewing the appeal, the reviewer’s decision including the medical rationale and evidence used as the basis for the decision, and instructions on how to file a second-level grievance hearing (NCGS 58-50-61(k)).
  

First-Level Grievance Reviews

• Reasons to File a grievance: Members have a right to file a grievance any time they are dissatisfied with any of a plan’s policies, decisions or actions. For example, members can file grievances if they are unhappy with the quality of care or the availability of health care services. Similarly, they can file grievances if the health plan fails to reimburse them for certain out-of-pocket payments that should have been covered by the plan (NCGS 58-50-62(b), 58-50-61(a)(6)).
  
  
• First Level Grievance Reviews: The member, his or her representative or the provider may submit a first-level grievance. The HMO must provide the member with information on how to submit written materials within three business days after receiving notice of the grievance. The person reviewing the grievance cannot be the same person who initially handled the grievance. If the issue is a clinical one, at least one of the reviewers must be a medical physician with appropriate expertise. The HMO must make a grievance decision within 30 days after receiving the complaint. The notice of the decision must include the same information as provided in first-level appeal decisions (NCGS 58-50-62(e)).
  

Second-Level Grievance Hearings

• Hearing Procedures: HMOs must also have second-level grievance reviews for members who are dissatisfied with the decision of the noncertification appeal or first level grievance review. The HMO must notify the member of the name and telephone number of the grievance coordinator, as well as information about the second-level grievance process within 10 days of receiving a request for a second-level grievance. Members have more extensive due-process rights at the second-level grievance review. Specifically, a member can attend the second-level grievance-hearing, request and receive all information relevant to the case in order to prepare for the hearing. A member may present his or her case to the review panel, submit supporting materials before and at the review meeting, ask questions of any member of the review panel and bring another person to help in the review hearing (such as a family member, employer representative or attorney). If the member chooses to bring an attorney, then an attorney may also represent the HMO (NCGS 58-60-62(f)(1)b).
  
  
• The HMO will convene a hearing panel to hear second-level grievances. The panel will usually be comprised of people who are not employees of the HMO or utilization review organization, who were not previously involved in the decision, and who do not have a financial interest in the outcome of the review. All of the people reviewing a second-level grievance involving a non-certification or clinical decision should be providers who have appropriate expertise² in the health issue in dispute. The review panel has up to 45 days to hold the hearing, and up to 15 days thereafter to make a decision. This decision is a recommended decision to the HMO.
  
  
• Expedited Hearings: Members can request an expedited second-level review if their health could be harmed because of any time delays (NCGS 58-60-62(i)). Members may request an expedited second-level review even if the first-level appeal or grievance review was not expedited. If necessary, the HMO may conduct the hearing over the phone or through submission of written information.
  
  
• Second-level Hearing Decisions: Each HMO must provide a written decision to the member and the person’s provider (if appropriate). The decision should contain the qualifications of the people reviewing the grievance, the reviewers’ decision, including the medical rationale for the decision and the evidence used as the basis for the decision. (NCGS 58-60-62(h)).
  

Members do not have the right to any further reviews after the second-level grievance hearing. However, a person with an outstanding complaint may still be able to seek help from the Department of Insurance in settling the dispute. The Department of Insurance’s Consumer Services Section answers the public’s complaints or questions about insurance companies. Sometimes the Department will intervene and try to negotiate a solution with the HMO when it thinks that the consumer has a justified complaint. The Department of Insurance’s telephone number is: 1-800-662-7777 or 1-800-546-5664.

¹ The appeals procedures do not apply to any non-certification given solely on the basis that a health benefit plan does not provide coverage for the health care services being requested if the exclusion of the specific service requested is clearly stated in the Evidence of Coverage (NCGS 58-60-61(a)(13)).

² If the HMO used a clinical peer in the noncertification appeal or a first-level grievance review panel, then the HMO may use one of its employees on the second-level grievance review panel (if the second-level panel consists of three or more people). (NCGS 58-60-62(f)(2)).

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