§ 58‑50‑79. Exhaustion of internal grievance process.
(a) Except as providedin G.S. 58‑50‑82, a request for an external review under G.S. 58‑50‑80or G.S. 58‑50‑82 shall not be made until the covered person hasexhausted the insurer's internal appeal and grievance processes under G.S. 58‑50‑61and G.S. 58‑50‑62.
(b) A covered personshall be considered to have exhausted the insurer's internal grievance processfor purposes of this section, if the covered person:
(1) Has filed a second‑levelgrievance involving a noncertification appeal decision under G.S. 58‑50‑61and G.S. 58‑50‑62, and
(2) Except to the extentthe covered person requested or agreed to a delay, has not received a writtendecision on the grievance from the insurer within 60 days since the date thecovered person can demonstrate that a grievance was filed with the insurer.
(c) Notwithstandingsubsection (b) of this section, a covered person may not make a request for anexternal review of a noncertification involving a retrospective review determinationmade under G.S. 58‑50‑61 until the covered person has exhausted theinsurer's internal grievance process.
(d) A request for anexternal review of a noncertification may be made before the covered person hasexhausted the insurer's internal grievance and appeal procedures under G.S. 58‑50‑61and G.S. 58‑50‑62 whenever the insurer agrees to waive theexhaustion requirement. If the requirement to exhaust the insurer's internalgrievance procedures is waived, the covered person may file a request inwriting for a standard external review as set forth in G.S. 58‑50‑80or may make a request for an expedited external review as set forth in G.S. 58‑50‑82.In addition, the insurer may choose to eliminate the second‑levelgrievance review under G.S. 58‑50‑62. In such case, the coveredperson may file a request in writing for a standard external review under G.S.58‑50‑80 or may make a request for an expedited external review asset forth in G.S. 58‑50‑82 within 60 days after receiving notice ofan appeal decision upholding a noncertification. (2001‑446, s. 4.5;2009‑382, s. 25.)
§ 58‑50‑79. Exhaustion of internal grievance process.
(a) Except as providedin G.S. 58‑50‑82, a request for an external review under G.S. 58‑50‑80or G.S. 58‑50‑82 shall not be made until the covered person hasexhausted the insurer's internal appeal and grievance processes under G.S. 58‑50‑61and G.S. 58‑50‑62.
(b) A covered personshall be considered to have exhausted the insurer's internal grievance processfor purposes of this section, if the covered person:
(1) Has filed a second‑levelgrievance involving a noncertification appeal decision under G.S. 58‑50‑61and G.S. 58‑50‑62, and
(2) Except to the extentthe covered person requested or agreed to a delay, has not received a writtendecision on the grievance from the insurer within 60 days since the date thecovered person can demonstrate that a grievance was filed with the insurer.
(c) Notwithstandingsubsection (b) of this section, a covered person may not make a request for anexternal review of a noncertification involving a retrospective review determinationmade under G.S. 58‑50‑61 until the covered person has exhausted theinsurer's internal grievance process.
(d) A request for anexternal review of a noncertification may be made before the covered person hasexhausted the insurer's internal grievance and appeal procedures under G.S. 58‑50‑61and G.S. 58‑50‑62 whenever the insurer agrees to waive theexhaustion requirement. If the requirement to exhaust the insurer's internalgrievance procedures is waived, the covered person may file a request inwriting for a standard external review as set forth in G.S. 58‑50‑80or may make a request for an expedited external review as set forth in G.S. 58‑50‑82.In addition, the insurer may choose to eliminate the second‑levelgrievance review under G.S. 58‑50‑62. In such case, the coveredperson may file a request in writing for a standard external review under G.S.58‑50‑80 or may make a request for an expedited external review asset forth in G.S. 58‑50‑82 within 60 days after receiving notice ofan appeal decision upholding a noncertification. (2001‑446, s. 4.5;2009‑382, s. 25.)
§ 58‑50‑79. Exhaustion of internal grievance process.
(a) Except as providedin G.S. 58‑50‑82, a request for an external review under G.S. 58‑50‑80or G.S. 58‑50‑82 shall not be made until the covered person hasexhausted the insurer's internal appeal and grievance processes under G.S. 58‑50‑61and G.S. 58‑50‑62.
(b) A covered personshall be considered to have exhausted the insurer's internal grievance processfor purposes of this section, if the covered person:
(1) Has filed a second‑levelgrievance involving a noncertification appeal decision under G.S. 58‑50‑61and G.S. 58‑50‑62, and
(2) Except to the extentthe covered person requested or agreed to a delay, has not received a writtendecision on the grievance from the insurer within 60 days since the date thecovered person can demonstrate that a grievance was filed with the insurer.
(c) Notwithstandingsubsection (b) of this section, a covered person may not make a request for anexternal review of a noncertification involving a retrospective review determinationmade under G.S. 58‑50‑61 until the covered person has exhausted theinsurer's internal grievance process.
(d) A request for anexternal review of a noncertification may be made before the covered person hasexhausted the insurer's internal grievance and appeal procedures under G.S. 58‑50‑61and G.S. 58‑50‑62 whenever the insurer agrees to waive theexhaustion requirement. If the requirement to exhaust the insurer's internalgrievance procedures is waived, the covered person may file a request inwriting for a standard external review as set forth in G.S. 58‑50‑80or may make a request for an expedited external review as set forth in G.S. 58‑50‑82.In addition, the insurer may choose to eliminate the second‑levelgrievance review under G.S. 58‑50‑62. In such case, the coveredperson may file a request in writing for a standard external review under G.S.58‑50‑80 or may make a request for an expedited external review asset forth in G.S. 58‑50‑82 within 60 days after receiving notice ofan appeal decision upholding a noncertification. (2001‑446, s. 4.5;2009‑382, s. 25.)
