§ 58‑50‑79.  Exhaustion of internal grievance process.

(a) Except as provided in G.S. 58‑50‑82, a request for an external review under G.S. 58‑50‑80 or G.S. 58‑50‑82 shall not be made until the covered person has exhausted the insurer's internal appeal and grievance processes under G.S. 58‑50‑61 and G.S. 58‑50‑62.

(b) A covered person shall be considered to have exhausted the insurer's internal grievance process for purposes of this section, if the covered person:

(1) Has filed a second‑level grievance involving a noncertification appeal decision under G.S. 58‑50‑61 and G.S. 58‑50‑62, and

(2) Except to the extent the covered person requested or agreed to a delay, has not received a written decision on the grievance from the insurer within 60 days since the date the covered person can demonstrate that a grievance was filed with the insurer.

(c) Notwithstanding subsection (b) of this section, a covered person may not make a request for an external review of a noncertification involving a retrospective review determination made under G.S. 58‑50‑61 until the covered person has exhausted the insurer's internal grievance process.

(d) A request for an external review of a noncertification may be made before the covered person has exhausted the insurer's internal grievance and appeal procedures under G.S. 58‑50‑61 and G.S. 58‑50‑62 whenever the insurer agrees to waive the exhaustion requirement. If the requirement to exhaust the insurer's internal grievance procedures is waived, the covered person may file a request in writing for a standard external review as set forth in G.S. 58‑50‑80 or 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‑level grievance review under G.S. 58‑50‑62. In such case, the covered person 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 as set forth in G.S. 58‑50‑82 within 60 days after receiving notice of an appeal decision upholding a noncertification. (2001‑446, s. 4.5; 2009‑382, s. 25.)