BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA (BCBSNC)
Updated 10/2000

These data reflect the most commonly purchased benefits package for each of the health plans in the year 2000.

HMO General Information
Background Information	BCBSNC received its HMO license from the NC Department of Insurance on September 2, 1981, and commenced business that same day. BCBSNC is a non-profit HMO. BCBSNC Personal Care Plan line of business is an HMO operated by Blue Cross Blue Shield of North Carolina.
Type of HMO	BCBSNC operates an IPA/network model HMO. That means that it contracts directly with physicians in the community or with networks of physicians.
Type of Products	BCBSNC’s most commonly purchased HMO plan is a "gatekeeper" product. In a gatekeeper system, you must choose a primary care provider who is responsible for managing all your care. For example, your primary care provider would be required to refer you to a specialist, or authorize a non-emergency admission to the hospital. BCBSNC also offers a point-of-service option, called "Medpoint." BCBSNC also operates two open-access products an open-access HMO product called "Blue Care," and an-open access point-of-service product called "Blue Choice." Open-access plans give members the authority to choose any PCP or specialist in the network without a referral.
Accreditation	BCBSNC received a Commendable accreditation from the National Committee for Quality Assurance (NCQA). NCQA looks at five categories in its accreditation process: access and services, qualified providers, staying healthy, getting better, and living with illness. An HMO seeking accreditation is evaluated on how well it meets NCQA’s standards in each of these areas. HMOs that fully meet NCQA’s standards receive a Commendable status. Those that meet most of NCQA standards receive an Accredited status. Provisional accreditation may be given for plans that meet some, but not all, of NCQA standards. Health plans that fail to meet NCQA’s requirements during the review will have their accreditation request Denied. A health plan’s accreditation status gives an idea of the quality of care provided by the plan as a whole. However, NCQA’s accreditation does not guarantee the quality of care provided to any individual member.
Enrollees	BCBSNC offers its HMO products to both large and small employer groups. It does not offer coverage to individuals ("non-group"), Medicare, or Medicaid recipients, although some Medicare beneficiaries may have supplemental HMO coverage through their employer.
Counties in which HMO has an Active Presence	BCBSNC had at least 25 commercial (group) members at the end of 1999 in the following counties: Alamance, Alexander, Anson, Ashe, Avery, Beaufort, Bertie, Bladen, Brunswick, Buncombe, Burke, Cabarrus, Caldwell, Carteret, Caswell, Catawba, Chatham, Cleveland, Columbus, Craven, Cumberland, Davidson, Davie, Duplin, Durham, Edgecombe, Forsyth, Franklin, Gaston, Granville, Greene, Guilford, Halifax, Harnett, Haywood, Henderson, Hertford, Hoke, Iredell, Jackson, Johnston, Jones, Lee, Lenoir, Lincoln, Macon, Madison, Martin, McDowell, Mecklenburg, Mitchell, Montgomery, Moore, Nash, New Hanover, Northampton, Onslow, Orange, Pamlico, Pasquotank, Pender, Person, Pitt, Polk, Randolph, Richmond, Robeson, Rockingham, Rowan, Rutherford, Sampson, Scotland, Stanly, Stokes, Surry, Swain, Transylvania, Union, Vance, Wake, Warren, Washington, Watauga, Wayne, Wilkes, Wilson, Yadkin, and Yancey.
Customer Service Number	1-800-311-2583
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services	Covers: General surgical and medical; intensive and cardiac care. Semiprivate room and board. (Private rooms covered in full if approved by BCBS). Use of operating, recovery, and delivery rooms; intensive care unit and diagnostic services. Meals and special diets when medically necessary. Therapy services; anesthesia and oxygen services; special duty nursing. The administration of whole blood plasma; and drugs and other inpatient services. Routine newborn nursery care. Limits: Prior approval required for non-emergency or maternity admissions. Cost Sharing: Coinsurance applies.
Outpatient services	Covers: Diagnostic services, therapy services, and other medically necessary services provided at a hospital outpatient department, ambulatory surgery facility or other health care facility. Limits: Some services require prior approval. Cost Sharing: Coinsurance applies.
Emergency care	Covers: emergency services within medical service area. Go immediately to nearest hospital emergency room for treatment or call your PCP or 24 hour nurse call center for advice. BCBS will pay for screening and treatment to stabilize your condition. Any follow-up care must be provided by your PCP. Emergencies outside service area: Follow same procedure as you would within the service area. Members must pay a copayment for emergency services unless admitted to the hospital. BCBS will not pay for follow-up care rendered outside of the service area unless the member cannot return to the services area because of medical reasons. You must request coverage for continuing and follow-up treatment from your PCP in order for it to be approved. Notification requirements: No authorization is required for maternity admissions for a stay of 48 hours for vaginal delivery or 96 hours for cesarean section. Approval must be requested if the member needs additional days. In other situations when the member is admitted to the hospital following an emergency, the member should contact BCBS as soon as possible to obtain approval for continued care. Limits: If you are unsure whether your condition is emergent, call your PCP or the 24 hour nurse line for direction on your care. If you live outside of the service area, you will be covered for immediate treatment of an emergency. Follow-up treatment must be arranged in advance by your PCP. Cost Sharing: Members must pay a copayment for emergency services unless admitted to the hospital. Excludes: Non-emergency use of the emergency room. If BCBS decides the condition did not require emergency care, you will be responsible for all charges unless you obtained preauthorization from BCBS.
Urgent Care	Within service area: Contact your PCP, call the 24 hour nurse line, or visit a participating urgent care provider. Use of an urgent care provider is limited to after-hour services, weekends or holidays. No PCP referral is needed to see an urgent care provider. However, routine or other non-urgent care will not be covered by BCBS. referrals from the PCP or nurse line for urgent care will be guaranteed payment. Services outside of service area: Contact your PCP by phone within 2 days or the first business day, whichever is later. If you are required to pay for urgent care services immediately, contact the Member Services Department to request a subscriber claim form. Note: If you live outside of the service area, services for urgent care will be covered if you received treatment within the service area from your PCP or from a participating urgent care Provider after normal doctor’s office hours, on weekends and/or holidays. Continued and follow-up treatment must be arranged in advance by your PCP. Cost Sharing: Copayments apply for urgent conditions. Excludes: If BCBS decides the condition did not require urgent care, you will be responsible for all charges.
Ambulance	Covers: Ambulance when medically necessary and when other forms of travelling may not be safe for your condition. Cost Sharing: Coinsurance applies.
Care for Students Outside of Service Area	Covers: Emergency and urgent care only unless the student enrolls in the "Guest Membership" program with BCBSNC before moving. Terms of coverage under "Guest Membership" will match those for the plan in the school’s service area.
Non-Urgent Care Outside of Service Area	Covers: Only extended period travelers who enroll in "Guest Membership" before traveling. Terms of coverage under "Guest Membership" will match those for the plan in the destination’s service area.
Professional Services
Professional Services (general)	Covers: Office visits and consultations, hospital and skilled nursing facility visits, periodic health checks. Coverage applies to visit with doctor, physician’s assistance, nurse practitioner or nurse midwife. Cost Sharing: Copayments or coinsurance may vary according to the type and time of the visit. For example, there may be a higher copayment for after-hours care.
OB/GYN	Covers: Services of OB/GYN for care related to the female reproductive system. referral not required. Cost Sharing: Copayments apply.
Diagnostic Procedures	Covers: Prescribed x-ray, laboratory and other diagnostic medical procedures. Screening mammograms available without referral. Limits: Prior approval is required for some services, such as MRIs.
Therapeutic Treatment Services	Covers: radiation, chemo-therapy, respiratory therapy services for conditions that are expected to show significant improvement through short-term respiratory therapy, as determined by the PCP. Limits: Visit limits may apply. Respiratory therapy limited to a maximum of 30 visits per calendar year. Cost Sharing: Copayment applies.
Chemotherapy	Covered.
Allergy Testing	Covered.
Preventive Services
Annual Physicals (well-baby, well-child)	Covers: Well-baby care and routine office visits, periodic health checks, as well as exams required for marriage, schools, employers and athletic teams. Cost Sharing: Copayments apply.
Immunizations	Covered.
Preventive Clinical Services	Covers: Pap smears, mammograms, and PSA tests (as required in state law).
Other Health Promotion/Disease Prevention Activities	Covers: Vision and hearing screenings.
Diabetic Treatment	Covers: All medically appropriate and necessary diabetic related services, including equipment, supplies, medications and laboratory procedures. Also covers diabetic outpatient self-management training and educational services. Limits: Limits may apply.
Conception Services
Prenatal Care and Obstetrical Services.	Covers: Prenatal and obstetrical services, including a minimum of 48 hours in the hospital after vaginal delivery or 96 hours after cesarean sections.
Family Planning	Covers: Diaphragms, and oral or injectable contraceptives (e.g. the pill, Depo-Provera). Also covers vasectomies and tubal ligations. Excludes: Other contraceptives, like Norplant and IUDs are excluded.
Abortion	Covers: Abortions up to the 16th week.
Infertility Services	Covers: 50% of medically necessary artificial insemination and prescription drugs used for the treatment of infertility. Infertility services and prescription drugs are limited to a combined $10,000 lifetime amount per Member. Excludes: Other means of artificial conception.
Mental Health and Substance Abuse Services
Mental Health Inpatient	Covers: Inpatient mental health services provided by Magellan, a specialized managed care organization the provides mental health and substance abuse services. Magellan contracts with providers and hospitals in your area. No referral needed from PCP before calling Magellan for mental health services. Limits: Coverage is limited to 30 days per calendar year for purposes of short-term evaluation and crisis intervention. Cost Sharing: A copayment required for each day of inpatient admission. Excludes: Coverage for developmental delay and/or learning differences, or for inpatient confinement needed to change the member’s environment.
Mental Health Outpatient	Covers: Individual and group therapy visits. Limits: Coverage limited to a combined total of 20-30 visits per calendar year for short-term evaluation and crisis intervention. Cost Sharing: Copayments vary for individual and group sessions, and number of visits by plan.
Substance Abuse Inpatient	Covers: Inpatient substance abuse services provided by Magellan, a specialized managed care organization the provides mental health and substance abuse services. Magellan contracts with providers and hospitals in your area. No referral needed from PCP before calling Magellan for mental health services. Limits: Coverage limited to 30 days per calendar year for the purpose of diagnosis and medical treatment for alcoholism and drug abuse. Inpatient and outpatient services, except detoxification, are subject to a combined $8,000 calendar year maximum and a $16,000 lifetime maximum. Cost Sharing: Copay required for each day. Detoxification: Provided on an inpatient or outpatient basis as medically necessary for an unlimited number of days.
Substance Abuse Outpatient	Covered Limits: Inpatient and outpatient services, except detoxification, are subject to a $8,000 calendar year maximum and a $16,000 lifetime maximum. Cost Sharing: Copay applies for each visit.
Prescription Drugs and Medical Supplies
Prescription drugs	Covers: Prescription drugs if medically necessary, prescribed by your PCP or an authorized medical specialist and on the approved BCBS prescription drug list ("formulary"). Other drugs that are not on the formulary can be covered with BCBS prior approval. Limits: Some prescription drugs may have quantity limits or require prior approval. Cost Sharing: When both generic and brand name medications are available, the copays for brand name drugs will be greater than copays for generic drugs. If the doctor writes "dispense as written," the member will only pay the copayment for a generic drug. Excludes: Drugs used for experimental or investigational purposes.
Blood	Covers: Costs of transfusions, blood, plasma, blood plasma expanders and other fluids injected into bloodstream.
Medical Supplies	Covers: Medical supplies, including colostomy bags, catheters, oxygen, needle, syringes, and special bandages. Cost Sharing: Coinsurance applies.
Insulin and Diabetic Supplies	Covers: Equipment, supplies, medications and laboratory procedures needed to treat diabetes. Also covers diabetic outpatient self-management training and educational services. Limits: Some equipment may require prior approval.
Durable Medical Equipment, Prosthetics, and Orthotics
Durable Medical Equipment (DME)	Covers: Equipment such as wheelchairs, braces, hospital beds, traction equipment, respiratory therapy and suction machines, prosthetic equipment, and other approved equipment. The repair or replacement of the equipment is provided if medically necessary. Limits: BCBS will decide whether to buy or rent the equipment. Payments are limited per calendar year. prior approval is required for purchases over a specified amount. Cost Sharing: Coinsurance applies. Coverage of customized DME: Not listed in Evidence of Coverage. Excludes: Eyeglasses, hearing aids, or "deluxe appliances." BCBS does not cover DME that are primarily for convenience purposes. If the equipment is determined to be no longer medically necessary, BCBS may ask it to be returned.
Prosthetic Devices	Covers: Purchase, fitting, necessary adjustments, repairs, and replacements of prosthetic devices and supplies that replace all or part of an absent body part. Coverage includes contiguous tissue or the replacement of all or part of the function of permanently inoperative or malfunctioning body parts. Cost Sharing: Coinsurance applies. Excludes: Dental appliances and replacement of cataract lenses, unless new cataract lenses are needed because of a prescription change.
Orthotic Devices	Covers: Rigid or semi-rigid supportive device that restricts or eliminates motion of a weak or diseased body part. Limits: Limited to a $250 lifetime maximum for foot orthotics. Cost Sharing: Coinsurance applies.
Rehabilitative and Habilitative Services
Physical Therapy	Covers: Outpatient short-term rehabilitation services for conditions that are expected to show significant improvement through short-term therapy, as determined by the PCP. Limits: Limited to a maximum of 30 visits per calendar year. Cost Sharing: Copayment applies.
Occupational Therapy	Covers: Outpatient short-term rehabilitation services for conditions which are expected to show significant improvement through short-term therapy, as determined by the PCP. Limits: Limited to a maximum of 30 visits per calendar year. Cost Sharing: Copayment applies.
Speech Therapy	Covers: Outpatient short-term rehabilitation services for conditions which are expected to show significant improvement through short-term therapy, as determined by the PCP. Limits: Limited to a maximum of 30 visits per calendar year. Cost Sharing: Copayment applies.
Pulmonary Therapy	Covers: Outpatient short-term respiratory services for conditions that are expected to show significant improvement through short-term therapy, as determined by the PCP. Limits: Limited to a maximum of 30 visits per calendar year. Cost Sharing: Copayment applies.
Cardiac therapy	Covered.
Chiropractic	Covers: Chiropractic services for conditions that are expected to show significant improvement through short-term therapy, as determined by the PCP. Limits: Limited to a maximum of 30 visits per calendar year. Cost Sharing: Copayment applies.
Other Therapy Services	Covers: medically necessary services that are not specifically excluded.
Skilled Nursing Facility	Covers: Limited to 60 days per calendar year. Cost Sharing: Coinsurance applies. Excludes: Custodial care.
Home-Based Services
Home Health	Covers: Skilled nursing, therapy services and other therapeutic services provided by home health agency. Benefits provided for home health aides only when skilled care required. Limits: Limited to a maximum of 60 days per calendar year per member. Prior approval is required. Cost Sharing: Coinsurance applies.
Private Duty Nursing	Covers: Services of a registered nurse (RN) or licensed practical nurse (LPN) when ordered by a doctor and authorized by BCBS. Limits: Prior approval is required. Cost Sharing: Coinsurance applies. Excludes: Coverage of a nurse who is a close relative, member of your household, or a sitter.
Hospice	Covers: Care of a terminally ill member with a life expectancy of six months or less. Excludes: Medical care rendered by a doctor, homemaker services such as cooking and housekeeping, food or meals, or private duty nursing services.
Transplants and Dialysis
Transplants	Covers: Organ, tissue, bone marrow transplants. This includes heart, combined heart and lung, lung (single and bilateral), simultaneous pancreas and kidney, liver, small bowel, kidney, cornea, simultaneous small bowel and liver, high dose chemotherapy with bone marrow or peripheral blood stem cell transplants. Limits: Prior approval is required. Not all participating facilities are approved transplant centers. Cost Sharing: Subject to applicable copays and/or coinsurance based on the type and location of the service. Donor expenses: Covers donor expenses, including expenses to locate a donor and/or diagnostic and pre-transplant care for the donor. Limit of $10,000 for donor expenses. BCBS will coordinate coverage for donor expenses with the donor’s health insurance ("coordination of benefits").
Dialysis	Covered.
Other Services
Dental	Covers: Care for accidental injury and congenital defects only. TMJ covered if unresponsive to conservative therapy and requires prior approval. Accidental treatment limited to services within 365 days of the accident. For injury, the first visit to the dentist does not require pre-approval by your PCP. Also covers dental care, treatment, and surgery due to tumor or cancer. Excludes: dental care, treatment, dental surgery and dental appliances, unless otherwise covered by a supplemental policy.
Vision	Covers: Comprehensive annual eye exam through a member of the Association of Eye Care Centers. Cost Sharing: Copayment applies. Excludes: Eye glasses or contact lenses unless following cataract surgery. Also excludes diagnostic services that are not part of a vision exam, medical or surgical treatment, medications that are not needed for a visual exam and unusual services, such as orthoptics. Vision training and low vision aids are also excluded.
Hearing	Excludes: Hearing aids and supplies, tinnitus maskers, or examination for the prescription of fitting of hearing aids.
Foot Care	Excludes: Palliative, cosmetic or routine foot care.
Weight Loss	Covers: Surgical treatment of obesity that is life threatening. Excludes: any other treatment or regimen, medical or surgical, for the purpose of reducing or controlling weight.
Smoking Cessation	Covers: Smoking cessation medications. Limits: Limited to one course of prescription drug treatment per calendar year or two courses of prescription drug treatment per lifetime.
Growth Hormones	Covered. Limits: Prior approval required. Prescription drug limitations and exclusions apply.
Alternative Therapies	Covers: Biofeedback for the following specific pain syndromes: migraine and muscle contraction headaches, muscle re-education or muscle tension, Reynaud’s phenomena, torticollis (including facial tics), and paralumbar or back pain. Excludes: Biofeedback for all other conditions.
Reconstructive/Cosmetic Surgery	Covers: Reconstructive breast surgery following a mastectomy. Coverage includes the surgery and reconstruction of non-diseased breast and prosthesis. Also covers surgeries for cancer and to correct congenital defects for children. This includes treatment and care of children born with cleft lip or cleft palate. Limits: Prior approval is required. Excludes: Cosmetic Surgery, except when necessary to correct condition resulting from trauma or accidental injury that occurred when member enrolled in BCBS.
Non-Emergency Transportation	Covers: Transportation for transplant recipient and one additional person.
Excluded Services
Experimental or Investigational Services	Excluded.
Services Not Considered Medically Necessary	Excluded.
Non-emergency services Rendered in Emergency Room	Excluded.
Commonly Excluded Services	See list of common exclusions.
Definitions
Medically Necessary	Definition of medically necessary follows statutory definition.
Experimental or Investigational	BCBS will decide that a service or supply is investigational if: The services or supplies requiring federal or other governmental approval do not have unrestricted market approval from the FDA or final approval from any other governmental regulatory body for use in treatment of a specific condition. There is insufficient or inconclusive scientific evidence to permit evaluation of the therapeutic value. There is inconclusive evidence that the service or supply has a beneficial effect on health outcomes. The service or supply is not as beneficial as any established alternative.
Emergency	Follows statutory definition.
Urgent Care	A condition that occurs suddenly and unexpectedly and requires prompt diagnosis or treatment or the member could reasonably be expected to suffer chronic illness, prolonged impairment, or the need for more hazardous treatment. Fevers over 101 degrees, ear infection, most fractures, sprains, lacerations, repeated kidney stones, and brief loss of consciousness are examples of urgent conditions.
Primary Cary Providers, Referrals and Pre-Authorization Requirements
Types of Providers Who Can Serve as Primary Care Provider	Family/General Practitioner, Internist, Pediatrician
What Happens if Member Fails to Choose a PCP?	The member will not be enrolled in the plan until they select a PCP.
Process to Change PCP	You may change your PCP at any time. You and your dependents may have different PCPs. You must select another PCP if your present PCP dies, moves outside the Medical Service Area, or becomes ineligible as a PCP in this plan. To change the PCP, you should complete a Personal Physician change form or call Member Services at least thirty days prior to the change.
referrals to Specialists	Your PCP must arrange for referrals to a medical specialist. BCBS will not pay for services provided by a medical specialist without prior written referral from your PCP and advance approval from BCBS. Referrals are not needed for female health services of an OB/GYN.
Can Specialists Serve as PCP	No.
Non-Emergency Hospital preauthorization requirements	You must use a local BCBS designated hospital or obtain approval from BCBS to use another hospital. Your PCP will make the arrangements that is required to contact BCBS for non-emergency admissions. You should be certain that the PCP has obtained the necessary authorization from BCBS before receiving non-emergency care by a hospital.
Appeal and Grievance Procedures
Informal Reconsideration	Members or their representatives must submit request informal reconsideration to BCBSNC within 60 days of the date of their claim. Members will receive a response from BCBSNC within 45 days of the PCP’s receipt of the review request.
First Level Non-Certification appeal Provisions	Follows statutory definition. Note: Members or their representatives must submit first level appeal in writing to BCBSNC within 60 days of the date of their informal reconsideration, UM or claims decision. Members will receive a response from BCBSNC within 30 days of the PCP’s receipt of the review request.
First Level Expedited Appeals	Follows statutory definition. Note: Responses to expedited appeals will be received within 72 hours of the receipt of all necessary information.
First Level Grievance Hearings	Follows statutory definition.
Second-Level Grievance Hearings (Covers Second-Level Appeals and Grievances)	Follows statutory definition. Note: Requests for second level grievance hearings must be made within 30 days of the first level grievance decision. The second level review meeting will be held within 45 days of the PCP receives a request for a second level grievance review. Member will be notified of the decision within 7 business days of the review meeting.
Second Level Expedited Appeals	Follows statutory definition. Note: Responses to expedited appeals will be received within 72 hours of the receipt of all necessary information.
Other Avenues of Appeal	Members can obtain independent information about the appeals process, and seek assistance from the NC Department of Insurance and the Office of Commissioner. Call 1-800-662-7777.
Notes	Limitations of Informal and Formal appeal and grievance Process: The appeal and grievance process does not apply to denials rendered solely on the basis that BCBSNC does not provide coverage for the health care service performed or being requested, as outlined in the Evidence of Coverage.
Enrollment Trends
Enrollment on December 31, 1999 (Financial Report, # 10)	209,520
Member months in 1999 (Financial Report, #11)	2,798,054
Average 1999 Monthly Enrollment (Member Months/12)	233,171
Percentage Change in Average Monthly Enrollment between 1998-1999	18.5%
Five-year Enrollment Trends	1999: 233,171 1998: 189,994 1997: 221,701 1996: 185,181 1995: 57,139
Percentage of Groups that Disenrolled (December 31, 1998-December 31, 1999)	30% (HMO) 22% (POS)
Percentage of Members that Disenrolled (December 31, 1998-December 31, 1999)	24.3% (HMO) 23.2% (POS)
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1998 — Dec. 31, 1999)	7% (HMO) 7% (POS)
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1998 — Dec. 31, 1999)	0% (HMO) 0% (POS)
Utilization Review Information
Number of reviews, 1999	215,087
Review Rate per 1,000 members, 1999	0.07
Percentage of Noncertifications, 1999	1.02%
Noncertification rate per 1,000 members, 1999	0.73
Appeal rate per 1,000 Noncertifictions, 1999	0.056
Percentage of Appeals Decided for the Members, 1999	0.02%
Financial Data
Total 1999 revenues (Financial Report, #6)	$220,170,000
Total Premium per member per month (Financial Report, #5 / #11), 1999	$145.97
Five-Year Premium per member per month Trends	1999: $145.97 1998: $127.08 1997: $116.63 1996: $111.94 1995: $135.18
Medical/Hospital Expenses per member per month (Financial Report, #7 / #11), 1999	$125.72
Medical Loss Ratio (% Premiums Spent on Medical/Hospital expenses) (Financial Report, #15), 1999	87.7%
Five-Year Medical Loss Ratio Trends	1999: 87.7% 1998: 93.5% 1997: 98.1% 1996: 100.5% 1995: 88.1%
Operating Profit Margin (Financial Report, #9 / #6), 1999	(1.0%)
Operating Profit Margin Trends	1999: (.890%) 1998: (.5%) 1997: (4.9%) 1996: (10.3%) 1995: (5.0%)
Sources of Information
Source of Information	Sample PCP Plan 1 6275, 12/97; 1998 Annual Financial Report; NC DOI Managed Care and Health Benefits Division, "HMOs in North Carolina Status Reports: Analysis of 1995 Activity" January 1997; NC DOI, "1999 Managed Care Plan Handbook: A Comparison Guide for North Carolina Consumers." Data on utilization review and Appeals and Grievances from NC DOI .

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