Overview
North Carolina HB 768 (2023) sets strict prior authorization timelines: 5 business days for standard requests and 2 business days for expedited requests. The law includes gold-carding provisions that exempt high-approval providers from routine PA requirements, streamlining care delivery.
Key Requirements
- Insurers must acknowledge PA requests within 24 hours and provide decision timeline.
- Standard PA decisions within 5 business days; expedited decisions within 2 business days.
- Providers with 90% approval rates and clean claim histories may qualify for gold-carding exemptions.
- Providers may request expedited review if standard timeline is medically inappropriate.
- Appeal procedures and external review access must accompany each denial.
Penalties and Enforcement
The North Carolina Department of Insurance enforces HB 768 PA requirements. Insurers who miss deadlines face fines. Providers may bill at usual and customary rates if insurer misses deadline. Repeat violations trigger license sanctions and increased penalties. Gold-carding compliance is monitored for consistency.
Appeals and Exceptions
Expedited PA requests receive 2-day response. Denials may be appealed within 10 business days. Independent external review is available if internal appeals fail. Certain denial codes may trigger automatic expedited review.
Interaction with Federal Law
North Carolina PA timelines align with federal standards. The 2-day expedited timeline exceeds federal requirements. Gold-carding rules align with CMS expectations. Providers benefit from North Carolina's streamlined approval process. NSA rules complement PA timelines.
Common Questions
What qualifies as expedited prior authorization in North Carolina?
Expedited PA applies when delay could jeopardize the patient's life, health, or ability to function. Conditions requiring hospitalization or emergency procedures are typically expedited.
Does North Carolina have gold-carding rules for prior authorization?
Yes. North Carolina HB 768 allows insurers to bypass routine PA for providers with 90% approval rates and clean claim histories.
Track North Carolina Prior Authorization Timelines Automatically
Altair monitors 5-day and 2-day deadlines and flags HB 768 violations. See how it works.
State laws change. This reference is current as of 2026-04-06. Consult state statutes or a healthcare attorney for definitive guidance.