23 CAR § 149-108. Appealing a denial of a request for exception

(a)(1) A patient covered by a healthcare insurer under a health benefit plan may appeal the denial of a request for a step therapy protocol exception. (2) The health benefit plan shall grant or deny the appeal within seventy-two (72) hours of receiving the appeal. (3) In cases in which exigent circumstances exist, the health benefit plan shall grant or deny the appeal within twenty-four (24) hours of receiving the appeal. (b) If a response by a healthcare insurer, health benefit plan, or utilization review organization is not received within the time allotted under this section, the appeal of a denial of a request shall be deemed granted. (c)(1) If an appeal is incomplete or additional clinically relevant information is required, a healthcare insurer, health benefit plan, or utilization review organization shall notify the prescribing healthcare provider within seventy-two (72) hours of submission, or twenty-four (24) hours in exigent circumstances, of the additional or clinically relevant information that is required in order to approve or deny the appeal. (2) Once the requested information is submitted, the applicable time period to grant or deny an appeal shall apply. (3) If a determination or notice of incomplete or clinically relevant information by a healthcare insurer, health benefit plan, or utilization review organization is not received by the prescribing healthcare provider within the time allotted, the appeal shall be deemed granted.