North Carolina § 58-50-75 - Purpose, scope, and definitions.

§ 58-50-75. Purpose, scope, and definitions.

The purpose of this Part is to provide standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of an appeal decision upholding a noncertification or a second-level grievance review decision upholding a noncertification, as defined in this Part. This Part applies to all insurers that offer a health benefit plan and that provide or perform utilization review pursuant to G.S. 58-50-61, the State Health Plan for Teachers and State Employees, and any optional plans or programs operating under Part 2 of Article 3A of Chapter 135 of the General Statutes. With respect to second-level grievance review decisions, this Part applies only to second-level grievance review decisions involving noncertification decisions. In addition to the definitions in G.S. 58-50-61(a), as used in this Part: "Covered benefits" or "benefits" means those benefits consisting of medical care, provided directly through insurance or otherwise and including items and services paid for as medical care, under the terms of a health benefit plan. "Covered person" means a policyholder, subscriber, enrollee, or other individual covered by a health benefit plan. "Covered person" includes another person, including the covered person's health care provider, acting on behalf of the covered person. Nothing in this subdivision shall require the covered person's health care provider to act on behalf of the covered person. "Independent review organization" or "organization" means an entity that conducts independent external reviews of appeals of noncertifications and second-level grievance review decisions. History (2001-446, s. 4.5; 2007-298, s. 8.5; 2007-323, s. 28.22A(o); 2007-345, s. 12; 2009-382, s. 24; 2014-115, s. 4.1.) Editor's Note. - Session Laws 2001-446, s. 4.2(4), effective July 1, 2002, and applicable to health benefit plans that are in effect, delivered, issued for delivery, or renewed on or after that date, designated G.S. 58-50-75 through 58-50-95 as Part 4 of Article 50, with the heading "Health Benefit Plan External Review." Session Laws 2001-446, s. 7 is a severability clause. Session Laws 2001-446, s. 8 provides: "Nothing in this act obligates the General Assembly to appropriate funds to implement this act." Effect of Amendments. - Session Laws 2007-298, s. 8.5, effective July 28, 2007, inserted "any optional plans or programs operating under Part 2 of Article 3 of Chapter 135 of the General Statutes," in the middle of the first sentence of subsection (b). Session Laws 2007-323, s. 28.22A(o), as amended by Session Laws 2007-345, s. 12, effective July 1, 2008, substituted "State Health Plan for Teachers and State Employees" for "Teachers' and State Employees' Comprehensive Major Medical Plan" in subsection (b). Session Laws 2009-382, s. 24, effective October 1, 2009, in subsection (b), in the first sentence, substituted "Article 3A" for "Article 3" and inserted "the North Carolina Health Insurance Risk Pool." Session Laws 2014-115, s. 4.1, effective August 11, 2014, in the first sentence of subsection (b), inserted "and" preceding "any optional plans" and deleted "the North Carolina Health Insurance Risk Pool, and the Health Insurance Program for Children" at the end.