reglab/housing_qa huggingface dataset:
NC Gen Stat § 58-50-75 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-75 - Purpose, scope, and definitions.

 58-50-75. Purpose, scope, and definitions.(a) 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.(b) 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.(c) In addition to the definitions in G.S. 58-50-61(a), as used in this Part:(1) "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.(2) "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.(3) "Independent review organization" or "organization" means an entity that conducts independent external reviews of appeals of noncertifications and second-level grievance review decisions.  (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.)
NC Gen Stat § 58-50-79 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-79 - Exhaustion of internal grievance process.

 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.)
NC Gen Stat § 58-50-84 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-84 - Binding nature of external review decision.

 58-50-84. Binding nature of external review decision.(a) An external review decision is binding on the insurer.(b) An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or State law.(c) A covered person may not file a subsequent request for external review involving the same noncertification appeal decision or second-level grievance review decision for which the covered person has already received an external review decision under this Part. (2001-446, s. 4.5.)
NC Gen Stat § 58-50-85 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-85 - Approval of independent review organizations.

 58-50-85. Approval of independent review organizations.(a) The Commissioner shall approve independent review organizations eligible to be assigned to conduct external reviews under this Part to ensure that an organization satisfies the minimum qualifications established under G.S. 58-50-87. The Commissioner shall develop an application form for initially approving and for reapproving organizations to conduct external reviews.(b) Any organization wishing to be approved to conduct external reviews under this Part shall submit the application form and include with the form all documentation and information necessary for the Commissioner to determine if the organization satisfies the minimum qualifications established under G.S. 58-50-87. Applicants must submit pricing information sufficient to demonstrate that if selected, the applicant's total fee per review will not exceed commercially reasonable fees charged for similar services in the industry. The Commissioner shall not approve any independent review organization that either fails to provide sufficient pricing information or has fees that do not meet the guidelines established under this subsection.(c) In order to be eligible for approval by the Commissioner, an independent review organization shall be accredited by a nationally recognized private accrediting entity that the Commissioner has determined has independent review organization accreditation standards that are equivalent to or exceed the minimum qualifications established under G.S. 58-50-87. The Commissioner may approve independent review organizations that are not accredited by a nationally recognized private accrediting entity if there are no acceptable nationally recognized private accrediting entities providing independent review organization accreditation.(d) An approval is effective for two years, unless the Commissioner determines before expiration of the approval that the independent review organization is not satisfying the minimum qualifications established under G.S. 58-50-87.(e) Whenever the Commissioner determines that an independent review organization no longer satisfies the minimum requirements established under G.S. 58-50-87, the Commissioner shall terminate the approval of the independent review organization.  (2001-446, s. 4.5; 2009-382, s. 31.)
NC Gen Stat § 58-50-89 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-89 - Hold harmless for Commissioner and independent review organizations.

 58-50-89. Hold harmless for Commissioner and independent review organizations.The Commissioner, an independent review organization, or a clinical peer reviewer working on behalf of an independent review organization shall not be liable for damages to any person for any opinions rendered during or upon completion of an external review conducted under this Part, unless the opinion was rendered in bad faith or involved gross negligence.  (2001-446, s. 4.5; 2002-187, s. 3.3; 2019-179, s. 6(c).)
NC Gen Stat § 58-50-90 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-90 - External review reporting requirements.

 58-50-90. External review reporting requirements.(a) An organization assigned under G.S. 58-50-80 or G.S. 58-50-82 to conduct an external review shall maintain written records in the aggregate and by insurer on all requests for external review for which it conducted an external review during a calendar year and submit a report to the Commissioner, as required under subsection (b) of this section.(b) Each organization required to maintain written records on all requests for external review under subsection (a) of this section for which it was assigned to conduct an external review shall submit to the Commissioner, upon the Commissioner's request, a report in the format specified by the Commissioner.(c) The report shall include in the aggregate and for each insurer:(1) The total number of requests for external review.(2) The number of requests for external review resolved and, of those resolved, the number resolved upholding the noncertification appeal decision or second-level grievance review decision and the number resolved reversing the noncertification appeal decision or second-level grievance review decision.(3) The average length of time for resolution.(4) A summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the Commissioner.(5) The number of external reviews under G.S. 58-50-80 that were terminated as the result of a reconsideration by the insurer of its noncertification appeal decision or second-level grievance review decision after the receipt of additional information from the covered person.(6) Any other information the Commissioner may request or require.(d) The organization shall retain the written records required under this section for at least three years.(e) Each insurer shall maintain written records in the aggregate and for each type of health benefit plan offered by the insurer on all requests for external review of which the insurer receives notice from the Commissioner under this Part. The insurer shall retain the written records required under this section for at least three years.  (2001-446, s. 4.5; 2009-382, s. 32.)
NC Gen Stat § 58-50-92 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-92 - Funding of external review.

 58-50-92. Funding of external review.The insurer against which a request for a standard external review or an expedited external review is filed shall reimburse the Department of Insurance for the fees charged by the organization in conducting the external review, including work actually performed by the organization for a case that was terminated due to the insurer's decision to reconsider a request and reverse its noncertification decision, prior to the insurer notifying the organization of the reversal pursuant to G.S. 58-50-80(j), or when a review is terminated pursuant to G.S. 58-50-80(h) because the insurer failed to provide information to the review organization. (2001-446, s. 4.5.)
NC Gen Stat § 58-50-93 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-93 - Disclosure requirements.

 58-50-93. Disclosure requirements.(a) Each insurer shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage it provides to covered persons.(b) The description required under subsection (a) of this section shall include a statement that informs the covered person of the right of the covered person to file a request for an external review of a noncertification, noncertification appeal decision or a second-level grievance review decision upholding a noncertification with the Commissioner. The statement shall include the telephone number and address of the Commissioner.(c) In addition to subsection (b) of this section, the statement shall inform the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review. (2001-446, s. 4.5.)
NC Gen Stat § 58-50-94 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-94 - Selection of independent review organizations.

 58-50-94. Selection of independent review organizations.(a) At least every two years, or more frequently if the Commissioner determines is needed to secure adequate selection of independent review organizations, the Commissioner shall prepare and publish requests for proposals from independent review organizations that want to be approved under G.S. 58-50-85. All proposals shall be sealed. The Commissioner shall open all proposals in public.(b) After the public opening, the Commissioner shall review the proposals, examining the quality of the services offered by the independent review organizations, the reputation and capabilities of the independent review organizations submitting the proposals, and the provisions in G.S. 58-50-85 and G.S. 58-50-87. The Commissioner shall determine which proposal or proposals would satisfy the provisions of this Part. The Commissioner shall make his determination in consultation with an evaluation committee whose membership includes representatives of insurers subject to Part 4 of Article 50 of Chapter 58 of the General Statutes, health care providers, and insureds. In selecting the review organizations, in addition to considering cost, quality, and adherence to the requirements of the request for proposals, the Commissioner shall consider the desirability and feasibility of contracting with multiple review organizations and shall ensure that, for any given type of case involving highly specialized services and treatments, at least one review organization is available and capable of reviewing the case.(c) An independent review organization may seek to modify or withdraw a proposal only after the public opening and only on the basis that the proposal contains an unintentional clerical error as opposed to an error in judgment. An independent review organization seeking to modify or withdraw a proposal shall submit to the Commissioner a written request, with facts and evidence in support of its position, before the determination made by the Commissioner under subsection (b) of this section, but not later than two days after the public opening of the proposals. The Commissioner shall promptly review the request, examine the nature of the error, and determine whether to permit or deny the request.(d) The provisions of Article 3C of Chapter 143 of the General Statutes do not apply to this Part.  (2001-446, s. 4.5; 2009-382, s. 33.)
NC Gen Stat § 58-50-100 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-100 - Title and reference.

 58-50-100. Title and reference.This section and G.S. 58-50-105 through G.S. 58-50-156 are known and may be cited as the North Carolina Small Employer Group Health Coverage Reform Act, referred to in those sections as "this Act". (1991, c. 630, s. 1; 2006-105, s. 1.9.)
NC Gen Stat § 58-50-105 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-105 - Purpose and intent.

 58-50-105. Purpose and intent.The purpose and intent of this Act is to promote the availability of accident and health insurance coverage to small employers, to prevent abusive rating practices, to require disclosure of rating practices to purchasers, to establish rules for continuity of coverage for employers and covered individuals, and to improve the efficiency and fairness of the small group accident and health insurance marketplace. (1991, c. 630, s. 1.)
NC Gen Stat § 58-50-112 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-112 - Affiliated companies; HMOs.

 58-50-112. Affiliated companies; HMOs.For the purposes of this Act, companies that are affiliated companies or that are eligible to file a consolidated tax return shall be treated as one carrier except that any insurance company, hospital service plan, or medical service plan that is an affiliate of an HMO located in North Carolina or any HMO located in North Carolina that is an affiliate of an insurance company, a health service corporation, or a medical service corporation may treat the HMO as a separate carrier and each HMO that operates only one HMO in a service area of North Carolina may be considered a separate carrier. (1991, c. 630, s. 1.)
NC Gen Stat § 58-50-115 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-115 - Health benefit plans subject to Act.

 58-50-115. Health benefit plans subject to Act.(a) A health benefit plan is subject to this Act if it provides health benefits for small employers and if any of the following conditions are met:(1) Any part of the premiums or benefits is paid by a small employer or any covered individual is reimbursed, whether through wage or adjustments or otherwise, by a small employer for any portion of the premium;(2) The health benefit plan is treated by the employer as part of a plan or program for the purpose of sections 106, 125, or 162 of the United States Internal Revenue Code; or(3) The small employer has permitted payroll deductions for the eligible enrollees for the health benefit plans.(b) Repealed by Session Laws 1993, c. 529, s. 3.5, effective January 1, 1995.(c) A health benefit plan is not subject to this Act if it provides health benefits for employers who are employer members of a Path 2 MEWA pursuant to Article 50A of this Chapter through a policy issued to the Path 2 MEWA.  (1991, c. 630, s. 1; 1993, c. 529, s. 3.5; 2013-357, s. 2(c); 2019-202, s. 4(b); 2020-69, s. 3(d).)
NC Gen Stat § 58-50-125 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-125 - Health care plans; formation; approval; offerings.

 58-50-125. Health care plans; formation; approval; offerings.(a), (a1) Repealed by Session Laws 2013-357, s. 2(e), effective January 1, 2015.(b) Repealed by Session Laws 2006-154, s. 9, effective July 23, 2006.(c) Except as provided under Article 68 of this Chapter, the plans developed under this section are not required to provide coverage that meets the requirements of other provisions of this Chapter that mandate either coverage or the offer of coverage by the type or level of health care services or health care provider.(d) If a small employer carrier offers coverage to a small employer, the small employer carrier shall offer coverage to all eligible employees of a small employer and their dependents. A small employer carrier shall not offer coverage to only certain individuals in a small employer group except in the case of late enrollees as provided in G.S. 58-50-130(a)(4b). A small employer carrier shall not modify any health benefit plan with respect to a small employer, any eligible employee, or dependent through riders, endorsements, or otherwise, in order to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the health benefit plan. In the case of an eligible employee or dependent of an eligible employee who, before the effective date of the plan, was excluded from coverage or denied coverage by a small employer carrier in the process of providing a health benefit plan to an eligible small employer, the small employer carrier shall provide an opportunity for the eligible employee or dependent of an eligible employee to enroll in the health benefit plan currently held by the small employer.(e) Repealed by Session Laws 2006-154, s. 9, effective July 23, 2006.(f) To the extent it is required under this section and G.S. 58-68-40, every small employer carrier shall fairly market all of its small group health benefit plans it offers on a guaranteed issue basis to all small employers in the geographic areas in which the carrier makes coverage available or provides benefits.(g) Repealed by Session Laws 2006-154, s. 9, effective July 23, 2006.(h) The provisions of subsection (d) of this section apply to every health benefit plan delivered, issued for delivery, renewed, or continued in this State or covering persons residing in this State on or after the date the plan becomes operational, as determined by the Commissioner. For purposes of this subsection, the date a health benefit plan is continued is the anniversary date of the issuance of the health benefit plan.  (1991, c. 630, s. 1; c. 761, s. 10; 1993, c. 529, s. 3.6; 1997-259, ss. 3, 4; 2006-154, ss. 1, 2, 9, 10, 14; 2013-357, ss. 2(d), (e).)
NC Gen Stat § 58-50-131 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 50 - General Accident and Health Insurance Regulations.|§ 58-50-131 - Premium rates for health benefit plans; approval authority; hearing.

 58-50-131. Premium rates for health benefit plans; approval authority; hearing.(a) No schedule of premium rates for coverage for a health benefit plan subject to this act, or any amendment to the schedule, shall be used in conjunction with any such health benefit plan until a copy of the schedule of premium rates or premium rate amendment has been filed with and approved by the Commissioner. Any schedule of premium rates or premium rate amendment filed under this section shall be established in accordance with G.S. 58-50-130(b). The schedule of premium rates shall not be excessive, unjustified, inadequate, or unfairly discriminatory and shall exhibit a reasonable relationship to the benefits provided by the contract of insurance. Each filing shall include a certification by an actuary who is a member of the American Academy of Actuaries and qualified to provide such certifications as described in the U.S. Qualifications Standards promulgated by the American Academy of Actuaries pursuant to its Code of Professional Conduct.(b) The Commissioner shall approve or disapprove a schedule of premium rates within 60 days of receipt of a complete filing. It shall be unlawful to use a schedule of premium rates until approved. If the Commissioner disapproves the filing, the Commissioner shall notify the filer, shall specify the reasons for disapproval, and shall provide an opportunity for refiling.(c) The Commissioner shall adopt rules as necessary or proper (i) to prevent the federal preemption of health insurance regulation in the State, (ii) to implement the provisions of this section, and (iii) to establish minimum standards for loss ratios of policies subject to this section in accordance with accepted actuarial principles and practices to assure that the benefits are reasonable in relation to the premium charged. The Commissioner shall adopt rules to require the submission of supporting data and any information that the Commissioner considers necessary or proper to determine whether the filed schedule of premium rates meets the standards set forth in this section.  (2011-196, s. 4; 2013-199, s. 9.)