North Carolina

STEP ONE – Notify Your Health Plan

The first thing you need to do is file a complaint with your health plan. If you’re having trouble filing a complaint with your health plan, the North Carolina Department of Insurance can help explain the appeals process and help you file an appeal. Follow the steps below to file a complaint and appeal with your health plan:

• Call the member/customer service phone number for your health plan.
• Tell them you want to file a formal complaint and then explain the problem.
• You can also file your complaint by letter, email, or online through your health plan’s website (see below).
• After receiving your first appeal, your health plan must provide contact information of their appeal coordinator.
• A medical doctor licensed in North Carolina who was not involved in the original decision must evaluate your appeal.
• Health plans must respond with their decision to your first appeal within 30 days.
• If you’re not happy with your health plan’s decision regarding the first appeal, you can file a grievance.
• Your health plan must hold a review hearing within 45 days of receiving your grievance request and issue a written decision within 7 days after the hearing.
• Contact the Department’s Health Insurance Smart NC Program at (855) 408-1212 for assistance or find more information here.

Below are links to the complaint forms for North Carolina’s top health plans:

• Aetna
• BlueCross Blue Shield of North Carolina
• Cigna
• UnitedHealthOne

Log on to MyUHC.com and complete the “Appeals and Grievance Form”
Select: Claims and Accounts > Medical Appeals and Grievances > Member Service Request Form
Fax or mail the completed form to the UnitedHealthcare address listed in the instructions

• My plan isn’t listed

Medicare Plans

STEP TWO – File a Complaint

You have the right to file a complaint with the North Carolina Department of Insurance (NCDOI) if you have a problem getting the services you need, including quality and affordable health care. If you are unsatisfied with your health plan’s decision regarding your appeal and grievance, you can request an External Review with the NCDOI. Find more information about the Department of Insurance here.

• Request an External Review by contacting the Health Insurance Smart N.C. Division: (855) 408-1212.
• The Smart N.C. Division reviews each case for eligibility. If accepted, the NCDOI assigns your case to an independent review organization for a final decision.
• Complete the External Review form on the NCDOI website here.