External Review Request Form

INSTRUCTIONS
Date: 12/14/2018
Information on Covered Person (Person who was denied the Services)
Title: First Name: Middle Name:
Last Name:
Address 1:
Address 2:
City: State: Zip Code:
Home Phone: Work Phone: Ext:
Fax Phone: Cell Phone:
Email:
Birth Date:  (mm/dd/yyyy)
 
Information on the Person Who is Authorized to Manage this Request for Covered Person
Title: First Name: Middle Name:
Last Name:
Address 1:
Address 2:
City: State: Zip Code:
Home Phone: Work Phone: Ext:
Fax Phone: Cell Phone:
Email:
Relation to Patient:
By checking this box, I the covered person, attest that I have obtained permission from this person to handle this external review on my behalf.
** IF YOU ARE A LEGAL GUARDIAN, POWER OF ATTORNEY OR EXECUTOR, PLEASE ATTACH/SUBMIT THE APPROPRIATE
DOCUMENTS TO REFLECT YOUR AUTHORITY TO REQUEST THIS REVIEW
 
Information on Doctor or Provider Who is Performing or Recommending the Service
Title: First Name: Middle Name:
Last Name:
Practice:
Address:
City: State: Zip Code:
Work Phone: Ext: Fax Phone:
 
About the Service that was Denied
The service that was denied is: 
The service in question has already been provided: Yes No
I have completed all levels of appeal offered by my Insurer: Yes No
 
Insurance Information
Insurance Company Name as it Appears on Card: 
Policy Number:
Group Number:
Policy Holder
First Name: Middle Name: Last Name:
Relation to Patient:
Birth Date:  (mm/dd/yyyy)
Employer/Group Name:
 
About the External Review I am Requesting
I am requesting a standard review -OR-
I am requesting an expedited review. I understand I cannot make this request if the service has already been provided.
I also further understand that a licensed medical professional will review this request to determine if the medical circumstances
warrant an expedited handling of my request. Supplying information (medical records or supporting information) from my treating
physician as to why this request should be handled expeditiously will help with the eligibility determination.

When submitting CDs please mail three copies by track able means (i.e. Fed-ex, UPS, or priority mail) to
Health Insurance Smart NC
1201 Mail Service Center, Raleigh NC 27699-1202
Please label your CDs with your first and last names for identification purposes.
 
Checklist
I have attached a copy of my insurance card
I have attached a copy of the final denial from my insurer
 
Description of Disagreement
 
Medical Authorization Release
The undersigned individual has requested an External Review pursuant to Part 4 Article 50 of Chapter 58 of the NC General Statutes. In order to perform that review the undersigned authorizes the North Carolina Department of Insurance ("NCDOI") to obtain from the Health Plan, whose decision is the subject of this request, and their sub-contractors, all information relating to the decision which is being reviewed including, but not limited to, his/her files and medical record information, which may include mental health information.

Payment of fees for obtaining these records is the responsibility of the undersigned. The Covered Person also authorizes the NCDOI to provide, or to instruct the Health Plan and/or its sub-contractors to provide, such information to the Independent Review Organization ("IRO") assigned by NCDOI to perform the External Review.

The undersigned also acknowledges the following:
  • NCDOI and/or the IRO may not be subject to the federal regulation pertaining to confidentiality and disclosure of medical records known as HIPAA. Despite the fact that HIPAA does not preclude NCDOI from re-disclosing medical record information, NCDOI and its agents are prohibited by North Carolina State law, specifically NCGS 58-2-105, from doing so for any purpose other than the review.
  • He/she may revoke this authorization at any time. Your revocation will be effective upon receipt, but will not affect actions already taken on the basis of this Authorization. In any event, this authorization will automatically expire upon NCDOI and/or the IRO rendering a final decision regarding this External Review.
  • Consent to the use of a translation service, at the expense of Smart NC, which shall treat the provided information as confidential, to translate any contents of this document that are submitted in a language other than English.
Type Name Here:
Date: 12/14/2018
ACKNOWLEDGEMENT OF RELEASE OF DRUG OR ALCOHOL ABUSE RECORDS
This area must be signed by the covered person/patient only when the records relating to the denied service contain information relating to drug or alcohol abuse. This should be signed in addition to the Medical Authorization Release.

I acknowledge that information to be used or disclosed as a result of this Authorization may include records that are protected by federal and/or state laws applicable to substance abuse. I SPECIFICALLY AUTHORIZE THE RELEASE OF CONFIDENTIAL INFORMATION RELATING TO DRUG AND/OR ALCOHOL ABUSE. The recipient of drug and/or alcohol abuse information disclosed as a result of this Authorization will need my further written authorization to re-disclose this information.
 
Signature of Covered Person if Applicable:
Date: 12/14/2018