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Authorize a Representative

Your health care information on file with the State Health Plan is private. That information, also known as your Protected Health Information (PHI), can be released only with your permission.

At times, someone else might need to see your PHI. For example, a relative or caregiver might need to learn more about your health care history in order to care for you. Only you can give the State Health Plan permission to let someone else see your PHI. To do so, you must first complete and submit the following form to the State Health Plan.

Authorization Form (PDF, 48KB)

Request Reimbursement

In most cases, health care providers and pharmacies will file your insurance claims for you, and you will pay only your copay out of pocket. However, providers who were not part of the Indemnity Plan network will ask for full payment directly from you. In those cases, if the services were normally covered by the Indemnity Plan, you can request that your expenses be reimbursed.

Use the appropriate form below to request reimbursement from the Indemnity Plan.

Medical Claim Form (PDF, 38KB)
Use this form to request reimbursement for health care services, such as a visit to a doctor not in the Indemnity Plan’s provider network. The Plan will only reimburse you up to the allowable, usual, customary, reasonable amount. Non-participating providers may bill you for the remainder of their charges.

Prescription Drug Claim Form (PDF, 45KB)
Use this form to request reimbursement for prescription drugs, such as those not purchased from a pharmacy contracted with the State Health Plan. Your reimbursement will be the Plan’s maximum allowable amount, not the charge for the prescription drug.

Appeal a Decision
Dispute the way a claim was paid.

Subrogation

The State Health Plan (“Plan”) has the right of subrogation upon Plan members’ right to recovery from liable third parties.  The Plan’s objective is to recover medical expenditures incurred by the Plan where a third party is liable for the care.  The recovering of such expenditures will ensure the financial viability of the Plan and allow it to continue to provide cost-efficient health care coverage to all its members. 

Please note that in accordance with North Carolina General Statute (N.C.G.S.) § 135-40.13A, the Plan is required to inquire about the terms of any third party recovery and disbursement to all lien holders if payment to the Plan is less than 100% of its lien. The Plan collects fifty (50%) percent of the total damages recovered by members after reasonable costs of collection have been subtracted from the total recovery. 

Members should contact Health Management Systems, Inc. (HMS), which has been contracted by the Plan to perform subrogation services, at 1-800-294-2757 to determine whether the Plan is claiming a right to recovery.  Alternatively, members may complete and fax the Lien Request form (PDF, 24KB) to 919-420-7835. Within five (5) business days HMS will provide a lien amount to members or their duly authorized representatives.


An Overpayment form (PDF, 14KB) is to be completed by providers for any overpayments due back to the Plan when a third party liability carrier has already paid. Please complete the information on the Overpayment Form to the extent known, attach the refund check and forward to NC State Health Plan, Overpayments, PO Box 20733 Raleigh, NC 27619. This information allows the Plan to properly credit members’ accounts and pursue other claims paid by the Plan where a third party is liable.

Reimburse the State

If you are injured as the result of an auto accident or other mishap caused by another person, your medical expenses will usually be covered by that person (often his or her auto or property insurance company). However, your immediate medical expenses will be covered by the State Health Plan while you wait for the other person to pay your expenses. Once you receive money from the other person, use the Overpayment form below to reimburse the State Health Plan for charges already paid.

Overpayment Form (PDF, 14KB)
Use this form to repay the State Health Plan if your medical expenses are paid for by both a third party and the State Health Plan. Such duplicate payments typically occur as a result of incidents such as auto accidents in which a third party is liable for your health expenses.

 
 
 

Health Plan Options