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July 2020

What can I do if my health insurance denies my medical claim as being "not medically necessary"?

Your health treatment has been denied because your health insurer says it is not "necessary"?

It's not unusual for health insurers to deny coverage for procedures and medications which they deem "not medically necessary."  Typically, this might start with a procedure which requires you to get advanced approval from the health insurance company.  Your doctor has probably submitted a request that the procedure be approved and your insurer has said that they do not believe the procedure or course of treatment is medically necessary.  At that point, you have to work through your own health insurer's internal appeals process.

Exhaust your internal appeals

The internal appeals may be a single step or may be multiple steps.  Make sure you go through all levels of internal review, also known as "exhausting remedies."  The appeal levels should be listed in your insurance contract or summary plan description.  If you don't have a copy, make sure you request one from the insurer.

If you exhaust the appeals within your health insurance company, and you have a certain type of health plan coverage, you can request an "External review" through the NC Department of Insurance. External review is available for most health insurers that make coverage decisions based on medical necessity. Other types of denial decisions are not eligible for external review.

Medical necessity decisions made by North Carolina State Health Plan are also subject to external review.

External review through DOI not available on certain plans

The NC Department of Insurance says that "North Carolina's state external review does not apply to self-funded employer health plans. (These are health plans for which an employer sets aside his own funds to pay for health claims rather than purchasing insurance, and are often "administered" by health insurance companies.) External review also does not apply to Medicare or Medicaid and is not available for certain types of insurance, including: dental, vision, Medicare supplement, long-term care, specified disease, workers compensation, credit, or disability income, or to medical payments under homeowners or auto insurance."

If your plan allows for external review visit the NC Department of Insurance Website to request an External Review

The North Carolina Department of Insurance runs the external reviews.  They are available whether you have already received a service and coverage for it has been denied or you have requested and been denied coverage for a service that you have not yet received.

Most people will qualify for a standard external review, which results in a decision within 45 days of submitting a request for review. An expedited external review, under which a decision is made within three days of submitting a request, is available in cases where the time involved in obtaining a final decision can have an impact on a person's health.

Yes, external review is free

There are no charges for the external review process. Hopefully, your medical providers will not charge you to fill in the forms for you saying the care was/is medically necessary.  Ask them when you send them the forms.  Usually they won't, because if you win the external review, then the health insurance company must pay for the procedure.

You should request your external review within 90 days of the denial of service.

Here is the link to review the process at the NC Department of Insurance:

https://www.ncdoi.gov/consumers/health-insurance/health-claim-denied/request-external-review

 

Chris Nichols

 

www.NicholsTrialLaw.com 1.800.906.5984

List of North Carolina Medicaid lien contacts for 2022 to request lien statements for personal injury cases

Hey wait, when did there get to be multiple insurers providing Medicaid benefits!?  And who do I contact to get a Medicaid lien?

Great questions!  Some answers:

Back on Feb. 4, 2019, the North Carolina Department of Health and Human Services announced the selection of Prepaid Health Plans that will participate in Medicaid managed care when the program launches in November 2019. The Department awarded contracts to five entities:

  • Statewide PHP contracts were awarded to the following entities which will offer Standard Plans in all regions in North Carolina:

        -  AmeriHealth Caritas North Carolina, Inc.

        -  Blue Cross and Blue Shield of North Carolina

        -  UnitedHealthcare of North Carolina, Inc.

        -  WellCare of North Carolina, Inc.

        - A regional PHP contract was awarded to Carolina Complete Health, a provider-led entity, which will offer plans in Regions 3 and 5.

Plaintiff lawyers who represent clients who are Medicaid recipients who have been in car wrecks need to track what these entities pay for medical treatment in order to account for the Medicaid lien and repay the government.

Before this privatization of Medicaid, all of the subrogation has been handled by a group called HMS.  Now that the PHPs have come along, we have to request subrogation information from each PHP.

Here is a list of the subrogation contacts for the Medicaid PHPs.

PHP Medicaid Lien Contact Information:

 

  • Carolina Complete Health

Rawlings Group

4 Eden Parkway

La Grange, KY  40031

Phone: 888-285-1276  

Fax: MANUAL FILE COORDINATOR at 502-440-1100

Email: CenteneReferrals@rawlingscompany.com

 

  • WellCare:

Rawlings Group

4 Eden Parkway

La Grange, KY  40031

Phone: 502-814-2489

Fax:  502-440-1080

 

  • Healthy Blue

 P.O. Box 659940

San Antonio, TX 78265-9939

Phone: 844-916-3651

Fax: 844-634-2520

Email: NCCompliance@healthybluenc.com

 

  • AmeriHealth

Attn: Subrogation Unit

200 Stevens Drive

Philadelphia, PA 19113
Phone: 215-863-5837

Fax: 215-863-5221
Email: subrogation@amerihealthcaritas.com

 

  • United Healthcare

Optum Subrogation

11000 Optum Circle

Eden Prairie, MN 55344

Fax: 800-842-8810

Email: subrogationreferrals@optum.com

 

  • Trillium:   www.trilliumnc.org 

Phone: 877-695-1296

Email: Trillium@gainwelltechnologies.com

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The subrogation providers above are subject to change, but this is the list as of 8/25/2022.

 

Chris Nichols

Nichols Law Firm

North Carolina and Raleigh Personal Injury Lawyer

www.NicholsTrialLaw.com 1.800.906.5984