Notice of Privacy Practices (PDF, 46 KB)

 

Your Review North Carolina Health Choice (NCHC) Rights

If you have questions or concerns about a decision to delay, deny, reduce, terminate or suspend your child’s Health Choice services, contact Customer Service. It may be possible for Customer Service to work with you to resolve your questions and/or concerns.

• For medical services, contact Customer Service at 1-800-662-7030
• For mental health, alcohol or drug treatment services, contact Customer Service at 1-800-753-3224 or fax the authorization requests to 1-877 339-8758.
• For pharmacy services, contact Customer Service at 1-800-662-7030.

---

Requesting a Review

You also have the right to request an internal first level review of the decision with the N.C. Department of Health and Human Services (DHHS) followed by an external second level review with the DHHS Hearing Office.  Both reviews must be completed within 90 calendar days of the date of receipt of the internal first level review request.

• You may request an internal first level review by writing a letter or filling out an Internal First Level Request for Review Form within 30 days of the date of the notice, even if you contact Customer Service. 
• If you disagree with the internal first level review decision, you may request an external second level review with the DHHS Hearing Office by writing a letter or filling out an External Second Level Review Request Form.

If you request a review by writing a letter, please include the following information:

• Child’s name
• Child’s Health Choice identification number
• Your telephone number
• Your address
• Date the service was provided
• Name(s) of the provider(s) of the service
• Reason for review request
• Letter about the benefit decision
• Documentation, if needed (such as medical records, letters from a doctor, etc.)
• Name of the representative in Customer Service who handled the inquiry
• If you have a lawyer or other representative you would like to assist you in the review process, please include the name, telephone number, and address of the person you would like to be your representative.  By designating a representative, you authorize DMA to release any and all medical records, other documents, and confidential information which may pertain to the review of this decision to your representative.
• Your signature and date on the letter.

Mail or fax your request to:

NC Health Choice-Directors Office
Review Coordinator
2501 Mail Service Center
Raleigh, North Carolina 27699-2501
Fax: 919-733-6608

NCHC Review Request Forms

• N.C. Health Choice First Level Review Request Form:
  • Adobe Acrobat Format (DMA-5072) (PDF, 40 KB)
  • en Español (PDF, 58 KB)
  • Adobe Acrobat Interactive Format (DMA-5072i) (PDF, 81KB)
• N.C. Health Choice Second Level Review Request:
  • Adobe Acrobat Format (DMA-5073) (PDF, 41 KB)
  • en Español (PDF, 40 KB)
  • Adobe Acrobat Interactive Format (DMA-5073i) (PDF, 91 KB)
• N.C. Health Choice Designation of Authorized Representative Form:
  • Adobe Acrobat Format (DMA-5071) (PDF, 71 KB)
  • en Español (PDF, 78 KB)
  • Adobe Acrobat Interactive Format (DMA-5071i) (PDF, 98 KB)
• N.C. Health Choice Receipt of Acknowledgement Letter Template:
  • en Español (PDF, 42 KB)

 

---

Review Process

The review process consists of two levels as described below.  Both levels of review must be completed within 90 calendar days of the date of receipt of the internal first level review request.

Internal First Level Review 

You have the right to an internal first level review by DMA's Clinical Medical Director or clinical designee, who will review the determination and any other information you submit.

• You must submit the request for an internal first level review within 30 days of the date of this notice.
• You will receive a written decision by certified mail.   
• The internal decision notice will provide further information about how you may request a second level review.

External Second Level Review

If you are not satisfied with the internal first level review decision, you may request an external second level review by the DHHS Hearing Office.

• You must request this review within 15 days of the date of the first level review decision.
• The DHHS Hearing Office will conduct a hearing in Raleigh, which you may attend in person or by telephone.
• At the hearing, you may represent yourself or have a representative, including an attorney at your expense.
• You will receive a written decision by certified mail.

Expedited Review

If your child’s physician determines that the standard 90-day time frame could seriously jeopardize your child’s life or health or ability to attain, maintain, or regain maximum function, you may request that the review be completed within an expedited time frame.  Under the expedited time frame, each level of review must be completed within 72 hours unless you request additional time (no more than 14 days may be allowed).

Review Decisions

All review decisions are based on coverage noted in the N.C. General Statutes and in the N.C. Health Choice medical policies.

When a Review Will Not Be Held

A review will not be held if the sole basis of the decision is a provision in the federal or state law requiring automatic change in coverage for all N.C. Health Choice enrollees without regard to individual circumstances.     

Services Provided During the Review Process

If the decision is to decrease the amount of service previously authorized, the service shall be covered at the amount authorized in the decision, unless and until the decision is overturned in the review process.  If the decision is to deny or terminate a service, the service will not be covered, unless and until the decision is overturned in the review process.

Enrollment

Your child will remain enrolled in the Health Choice program during the review process as long as he or she is eligible.