Short Answer

In North Carolina, you can dispute a health plan’s claim that all treatment is “accident-related” by filing a timely internal appeal and, for insured plans, requesting an external review through the state. Only medical charges caused by the accident may be taken from your injury recovery under North Carolina’s medical lien laws. Build your challenge with itemized bills, coding details, and a provider letter explaining which care was unrelated. Act before the appeal deadline shown on your Explanation of Benefits.

Understanding the Problem

In North Carolina, can you push back when your health plan says your medical care is “accident-related” and refuses to pay (or seeks reimbursement from your settlement) even though some treatment had nothing to do with the crash? The decision point is whether the disputed charges were actually caused by the accident, so you can challenge the plan’s classification and limit any repayment to truly related care.

Apply the Law

Under North Carolina law, only reasonable charges for medical care caused by the accident can be recovered from your injury settlement. Your health coverage can still be primary or coordinated depending on plan terms, but you have the right to appeal a denial or reimbursement demand that overreaches. Start with the plan’s internal appeal process (the claims administrator is the forum); most plans give a defined appeal window from the date on your Explanation of Benefits. Fully insured plans generally allow for state-supervised external review after the plan’s final denial; self-funded employer plans follow a federal external review process set out in the plan’s notice.

Key Requirements

• Identify the dispute: Pin down which bills or codes the plan marked “accident-related” and why (rely on the EOB and itemized statements).
• Gather proof: Obtain a brief letter from your treating provider and records showing which diagnoses and treatments were unrelated to the accident.
• Appeal on time: File a written internal appeal with the plan within the stated deadline (commonly 180 days from the EOB).
• Use external review when available: For insured plans, request an external review through North Carolina’s process after the plan’s final denial if eligibility/medical-necessity is at issue.
• Limit any lien to caused care: In disbursing a settlement, only accident-caused, reasonable medical charges are lienable and the total health care liens are capped by statute.

What the Statutes Say

• North Carolina Gen. Stat. § 44-49 (Medical provider lien) - Creates a lien on personal injury recoveries for reasonable charges for accident-related medical care.
• North Carolina Gen. Stat. § 44-50 (Enforcement and cap) - Limits total health care liens to a portion of the net recovery and governs disbursement.
• North Carolina Gen. Stat. § 58-50-61 (External review) - Provides a state external review process for certain adverse health benefit determinations on insured plans.

Analysis

Apply the Rule to the Facts: Because only accident-caused care can be treated as “related,” start by separating the bills tied to the crash from routine or preexisting-care bills. Support the split with a provider note and itemized statements showing diagnosis codes. Appeal the plan’s determination in writing within the stated deadline and ask the plan to reprocess the unrelated charges. If the plan maintains its position, pursue external review (if insured) and keep any settlement lien limited to accident-caused, reasonable amounts.

Process & Timing

1. Who files: The plan member. Where: First to your health plan’s claims administrator; then, if insured and eligible, to the North Carolina Department of Insurance for external review. What: A written internal appeal with itemized bills, medical records, and a provider letter; then a Request for External Review after a final denial. When: File the internal appeal within the deadline on the EOB (commonly 180 days); request external review within the window stated in the final denial notice.
2. The plan reviews and issues a decision; standard internal appeals are typically decided within several weeks. If you request external review, an independent reviewer usually issues a decision within a defined timeframe listed in your notice.
3. If you resolve coverage, your settlement is disbursed with only valid accident-related medical liens paid, subject to statutory caps. If a provider insists on including unrelated charges, your attorney can seek court guidance before funds are released.

Exceptions & Pitfalls

• Plan type matters: Self-funded employer plans are governed by federal rules and may not be subject to North Carolina’s external review; follow the plan’s federal external review directions.
• Missed deadlines: Late appeals are often rejected—calendar the appeal window the day you receive the EOB.
• Coding errors: Incorrect diagnosis or accident modifiers can mislabel unrelated care; ask your provider’s billing office to correct and resend claims.
• Overbroad liens: Providers may include unrelated balances in a lien; challenge scope and pay only accident-caused, reasonable charges within the statutory cap.
• Notice gaps: Keep proof of mailing/emailing appeals and attachments; incomplete submissions can delay or derail review.

Talk to a Personal Injury Attorney

If you’re dealing with a health plan labeling all treatment as accident-related when some care was not, our firm has experienced attorneys who can help you understand your options and timelines. Reach out today.

Disclaimer: This article provides general information about North Carolina law based on the single question stated above. It is not legal advice for your specific situation and does not create an attorney-client relationship. Laws, procedures, and local practice can change and may vary by county. If you have a deadline, act promptly and speak with a licensed North Carolina attorney.