---
title: "Ambetter of North Carolina appeal form and deadline"
url: "https://denialfacts.com/insurers/ambetter-of-north-carolina-inc--nc"
publisher: "Axion Labs — Denial Facts"
checked: "2026-11-04"
dataset_fixity: "sha256-cda2f9b89c8dde2a74989a35dbe7c0d08ff35dac5456484dc1c03c1b181a67b6"
---

# Ambetter of North Carolina denied your claim. Here is your deadline.

Denied by Ambetter of North Carolina? Your two appeal deadlines dated from your notice, a free letter, and its 12.2% denial rate.

## Figures

| Figure | Value |
| --- | --- |
| In-network denial rate | 12.2% |
| Claims denied | 708,961 |
| Plans in North Carolina | 34 |
| Internal appeals filed | 1,764 |
| Internal overturn rate | 52.38% |
| In-network claims received | 5,831,495 |
| External reviews filed | not reported |
| External overturn rate | not reported |
| National denial rate | 15.7% |

## External-review route

**State-run process.** North Carolina runs its own external review process meeting the federal standards, so an independent review there is handled through the state program rather than the federal one. This route is the one for insured plans, Marketplace, individual, and employer plans where an insurance company carries the risk. If your coverage is through a job and the employer pays the claims itself (a self-funded or self-insured plan, which is 63% of covered workers), the state process does not apply to you whatever your state operates, and your external review goes through the federal process instead. Your denial letter names your route; if it does not, ask your plan in writing whether the plan is self-funded.

## Denials by reason

| Reason | Claims | Share of this insurer's categorized denials |
| --- | --- | --- |
| Referral required | 232,527 | 17.6% |
| Service excluded from the plan | 232,396 | 17.6% |
| Not medically necessary | 211,124 | 16% |
| Administrative reason | 187,806 | 14.2% |
| Other reasons | 160,644 | 12.1% |
| Provider out of network | 105,127 | 7.9% |
| Benefit limit reached | 104,880 | 7.9% |
| Member not covered | 88,821 | 6.7% |

## Ambetter of North Carolina in North Carolina, at the top of the page

North Carolina

Your two dates, free

Date on your denial notice

Who pays your claims?

A job, an insurance company pays the claims

A job, my employer pays the claims itself (self-funded)

A job, I do not know which

Marketplace / individual plan I bought myself

Medicare, Medicaid, TRICARE, VA or IHS

Which state?

The reason your letter gives

I'm not sure, I'll paste the sentence later

Not medically necessary
Provider out of network
Service excluded from the plan
Experimental or investigational
Referral required
Benefit limit reached
Member not covered
Administrative reason
Other reasons

Show my two dates, free

Put in the date on your Ambetter of North Carolina Inc. notice and get both federal deadlines as calendar dates.

Free, for an Ambetter of North Carolina Inc. denial in North Carolina, and it runs entirely in your browser. The date, the plan type and the state you pick are never sent to us and never stored.

Ambetter of North Carolina Inc. denied 708,961 of 5,831,495 in-network claims in North Carolina; every one of those denials had these same two dates on it. Across North Carolina as a whole the insurers in this file denied 19.7% of in-network claims, 5,857,465 of them, and 6,532 were appealed.

Or let the [$29 Appeal Kit](/appeal-kit) date each step and write the claim-file and external-review requests.

Ambetter of North Carolina Inc. denied 12.2% of in-network claims in North Carolina, 708,961 claims out of 5,831,495.

By [Axion Labs](/about) · August 19, 2026, updated November 4, 2026

Further down this page, after the free steps: the paid next step .

Insurance got denied, what to do next?

We hear this most. [r/HealthInsurance, thread title](https://www.reddit.com/r/HealthInsurance/comments/1rdxwvi/insurance_got_denied_what_to_do_next/) , read September 3, 2026.

The number nobody else publishes, and here it is missing. CMS publishes no external-review figure for Ambetter of North Carolina Inc. in North Carolina, so nobody, including the regulator, can say whether anyone ever got that far. We print no number rather than reading an absence as a zero. Nationally, 4,918 of 83,907,852 denials reached that stage, one in every 17,061, and 22.2% (1,092 of 4,918; interval 22.2-23.8% for counts CMS withheld; 32.6% without SelectHealth) of those were overturned.

Those 708,961 denials are 12.1% of every in-network denial recorded in North Carolina in this release, which makes Ambetter of North Carolina Inc. the 2nd largest source of denials of the 5 insurers reporting there. Spread across its 34 plans in the state that is about 20,852 denials per plan. 1,764 internal appeals were filed against those 708,961 denials. Every one of those denials carried the same two dates the tool at the top of this page works out.

The clock your letter has to describe, in actual dates

Two dates matter more than anything else on this page, and they run the same in North Carolina as everywhere else. You have 180 days from the date on your denial notice to file the internal appeal, and then 4 months from the final internal denial to ask for an independent external review. If waiting would seriously jeopardize your health you can ask for both to be expedited, decided in about 72 hours . Both timeframes are federal, not your insurer's choice, [29 CFR 2560.503-1](https://www.ecfr.gov/current/title-29/section-2560.503-1) ( [PDF](https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol9/pdf/CFR-2024-title29-vol9-sec2560-503-1.pdf) ) and [45 CFR 147.136](https://www.ecfr.gov/current/title-45/section-147.136) ( [PDF](https://www.govinfo.gov/content/pkg/CFR-2024-title45-vol2/pdf/CFR-2024-title45-vol2-sec147-136.pdf) ), in plain English at [HealthCare.gov](https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/) , and your own denial letter states the ones that govern your plan. The PDFs are the same sections on govinfo.gov, which serves them without a challenge page, so an automated reader can check these two dates as easily as you can.

Data verified November 4, 2026 · CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain

You are not alone, and here is the measured version of that sentence: 708,961 in-network claims were denied by Ambetter of North Carolina Inc. in North Carolina in a single plan year. A denial rate is a fact about an insurer's book of business. It is not a judgment about you, and it is not the last word on your claim.

- Of the 5 insurers reporting a denial rate in North Carolina, Ambetter of North Carolina Inc. is the fifth highest at 12.2%. The highest in the state is 26.2% and the lowest is 12.2%.

- That is 3.5 percentage points below the 15.7% national average across this dataset, and 7.5 points below the North Carolina average of 19.7%.

- Behind the percentage: 5,831,495 in-network claims were processed under 34 plans in North Carolina, and 708,961 of them came back denied.

- For every 10,000 claims Ambetter of North Carolina Inc. denied, about 25 came back as an internal appeal. The other 9,975 stopped at the letter.

- Of the internal appeals it did receive, Ambetter of North Carolina Inc. overturned 52.38% , 924 claims that started life as a no.

- Its most-recorded denial reason is referral required at 17.6% of its categorized denials, against 9.6% nationally, a heavier share than the country as a whole. That is the denial mix, not an outcome rate.

- Ambetter of North Carolina Inc. accounts for 12.1% of every in-network claim denied in North Carolina in this file.

- By raw volume it is the 26th largest source of denials among the 135 insurer-state records in the file that report one.

- After that, its second-most-recorded reason is [service excluded from the plan](/denial-reasons/service-excluded) , 232,396 claims, 17.6% of its categorized denials.

- Third on its own list is [not medically necessary](/denial-reasons/not-medically-necessary) , 211,124 claims, 16% of what Ambetter of North Carolina Inc. categorized in North Carolina. Between them the top three account for 51.1% of its categorized denials.

- Where Ambetter of North Carolina Inc. differs most from the national mix is [not medically necessary](/denial-reasons/not-medically-necessary) : 16% of its categorized denials in North Carolina against 5.5% across the file.

- Read the other way round: 5,122,534 of those 5,831,495 in-network claims were paid, 87.8% of everything Ambetter of North Carolina Inc. processed in North Carolina.

- Spread across the 34 plans it reports in North Carolina, that is about 20,852 denied claims per plan, on about 171,515 claims processed per plan.

- Its reason columns add up to 1,323,325 categorized rows against 708,961 denials, 186.7% of them, and every reason share on this page is a share of that first figure rather than of the second.

- Its smallest recorded category in North Carolina is [member not covered](/denial-reasons/member-not-covered) , 88,821 claims, 6.7% of what Ambetter of North Carolina Inc. categorized there.

- Against the file as a whole, this one record is 0.8% of the 83,907,852 in-network claim denials reported by every issuer in it.

What to do tonight

- Find the reason code on your denial letter. The reason Ambetter of North Carolina Inc. records most often in North Carolina is referral required , but yours may be one of the other 8, copy the exact wording and code off your own letter tonight, because that sentence is what your appeal has to answer.

- Ask Ambetter of North Carolina Inc. in North Carolina for the clinical criteria they judged you against. Under [29 CFR 2560.503-1](https://www.ecfr.gov/current/title-29/section-2560.503-1) they have to hand you the claim file and the policy they applied, free, on request, and you cannot argue with a checklist you have never read.

- Put both deadlines on your calendar before you go to bed. 180 days from the date on the letter for the internal appeal, 4 months from the final internal denial for external review. The free calculator on this page turns your date into the two calendar dates in about ten seconds. Ambetter of North Carolina Inc. overturned 52.38% of the internal appeals it did receive, 924 claims, so the stage you are about to start is not decorative.

None of those three steps costs anything. Anyone charging you to do them is selling you something you can do yourself in twenty minutes.

12.2%

In-network denial rate

708,961

Claims denied

34

Plans in North Carolina

1,764

Internal appeals filed

52.38%

Internal overturn rate

## How that compares

| Denial rate | Rate | Difference |
| --- | --- | --- |
| Ambetter of North Carolina Inc. | 12.2% | , |
| North Carolina average | 19.7% | -7.5 pts |
| National average (this dataset) | 15.7% | -3.5 pts |

Ambetter of North Carolina Inc. sits at or below the national average across this dataset. A denial rate is a property of the insurer's book of business, coding practice, plan design, the population it covers, not evidence about the merits of any one claim, including yours.

## What happened to appeals

| Stage | Filed | Overturned |
| --- | --- | --- |
| Internal appeal (to Ambetter of North Carolina Inc.) | 1,764 | 52.38% |
| External review (independent) | not reported | not reported |

Read the table for what it is: the external-review row above shows a dash, which means not reported and not zero, the North Carolina absence this page states once at the top for Ambetter of North Carolina Inc. and sources once at the foot. External review is free to you and the insurer must follow the decision, whatever this file does or does not record about it.

What that record means for your own Ambetter of North Carolina Inc. letter, and by when. Ambetter of North Carolina Inc. overturned 52.38% of the 1,764 internal appeals its North Carolina members filed against 708,961 denials, and the North Carolina escalation count for Ambetter of North Carolina Inc. is the figure this page names as absent at the top, so how many of those denials went on to the independent stage is not something this page can tell you, Ambetter of North Carolina Inc.'s own rows in the plan-year 2027 release of the CMS Transparency in Coverage file, read November 4, 2026 ( [data.healthcare.gov](https://data.healthcare.gov/) ). Whichever way that lands, nobody files the appeal for you, and the filing runs on a clock set by which plan you hold: an employer or Marketplace plan gives you at least 180 days from the denial notice to file the internal appeal ( [29 CFR 2560.503-1(h)(3)(i)](https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol9/pdf/CFR-2024-title29-vol9-sec2560-503-1.pdf) , carried onto individual-market coverage by [45 CFR 147.136(b)(3)(i)](https://www.govinfo.gov/content/pkg/CFR-2024-title45-vol2/pdf/CFR-2024-title45-vol2-sec147-136.pdf) ), while Medicare Advantage gives you 65 calendar days from the date of its notice ( [CMS](https://www.cms.gov/medicare/appeals-grievances/managed-care/reconsideration-advantage-health-plan-part-c) , [42 CFR 422.582(b)](https://www.ecfr.gov/current/title-42/section-422.582) ) and Medicaid managed care 60 calendar days from the date on the notice ( [42 CFR 438.402(c)(2)(ii)](https://www.ecfr.gov/current/title-42/section-438.402) ), both stages free, and the three steps above are the whole of what to do tonight, so take the date printed on your Ambetter of North Carolina Inc. notice and file well inside whichever of those windows is yours. The free steps are above; the [$29 kit](/appeal-kit) is the same clock with the letters pre-filled for Ambetter of North Carolina Inc. in North Carolina. One payment. No subscription. No cut of your claim.

## Ambetter of North Carolina Inc. inside North Carolina

Your denial did not happen in a national average. It happened in a state market, alongside 4 other insurers reporting into the same federal file, and these are that market's own figures.

- Across the whole of North Carolina, the 5 insurers reporting in this file processed 29,684,141 in-network claims and denied 5,857,465 of them, a state denial rate of 19.7%. Ambetter of North Carolina Inc. is one of those 5.

- That puts North Carolina sixth of 29 states by denial rate, 4 points above the 15.7% national average, before you get to what Ambetter of North Carolina Inc. did inside it.

- North Carolina recorded 6,532 internal appeals against those denials: one appeal for every 897 claims the state's insurers refused. Ambetter of North Carolina Inc.'s own ratio is one for every 402.

- Independent external review was reached 121 times in the whole of North Carolina, once for every 48,409 denials, against one in 17,061 nationally. How many came from Ambetter of North Carolina Inc.'s denials is not on the record, that is the North Carolina figure this page names as absent at the top and sources at the foot.

- Of the North Carolina external reviews that were filed, 54 were overturned, 44.6%. That percentage is measured on 121 reviews, which is why the count beside it matters more than the rate does when you are deciding whether to file against Ambetter of North Carolina Inc..

- The reason North Carolina's insurers record most often is [other reasons](/denial-reasons/other) , 2,323,043 claims, 36.1% of the state's categorized denials. Ambetter of North Carolina Inc. records referral required most often instead, which is the argument your letter will need to answer.

- The other insurers a North Carolina reader could have bought from run from 26.2% ( [AmeriHealth Caritas North Carolina, Inc.](/insurers/amerihealth-caritas-north-carolina-inc--nc) ) to 12.8% ( [Oscar Health Plan of North Carolina, Inc](/insurers/oscar-health-plan-of-north-carolina-inc--nc) ). Ambetter of North Carolina Inc. at 12.2% sits below all of them.

- Put the two together and Ambetter of North Carolina Inc. is responsible for 12.1% of every in-network claim denied in North Carolina in this release, from 19.6% of the claims the state's insurers processed.

- Every North Carolina figure in this section is that state's own row in the same federal file Ambetter of North Carolina Inc.'s numbers above come from, [CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain](https://data.healthcare.gov/) , and the full North Carolina page is free at [/states/north-carolina](/states/north-carolina) .

## What Ambetter of North Carolina Inc. denies most

The most common denial reason recorded for Ambetter of North Carolina Inc. plans in North Carolina is referral required . [How that denial is beaten →](/denial-reasons/referral-required)

| Denial reason | Claims | Share | National share |
| --- | --- | --- | --- |
| Referral required | 232,527 | 17.6% | 9.6% |
| Service excluded from the plan | 232,396 | 17.6% | 13.4% |
| Not medically necessary | 211,124 | 16% | 5.5% |
| Administrative reason | 187,806 | 14.2% | 17.2% |
| Other reasons | 160,644 | 12.1% | 32.4% |
| Provider out of network | 105,127 | 7.9% | 9% |
| Benefit limit reached | 104,880 | 7.9% | 4.9% |
| Member not covered | 88,821 | 6.7% | 7.9% |

The last column is each reason's share of all categorized denials nationally, so you can see where Ambetter of North Carolina Inc.'s mix in North Carolina differs from everyone else's. This is denial mix , not overturn rate by reason , the federal file does not report appeal outcomes broken down by denial reason, and we do not imply otherwise.

Work out your two deadlines

Put the date from your notice in and get the two calendar dates, with the days remaining.

Date on your denial notice

Which denial is this?

First denial (I have not appealed yet)

Final internal denial (my appeal was refused)

Show my deadlines

Runs entirely in your browser, the date you type is never sent to us and never stored. [Open the full calculator →](/appeal-deadline-calculator)

Or let the [$29 Appeal Kit](/appeal-kit) date each step and write the claim-file and external-review requests.

The three steps at the top of this page are the whole of what you have to do tonight. The longer
version, what the internal appeal has to contain, how the independent stage works, and how to ask
for expedited handling when waiting would seriously jeopardize your health, is
[published free here](/how-to-appeal) . For what it is worth on this page specifically: Ambetter of North Carolina Inc. overturned 52.38% of the internal appeals it received.

## Who appeals what at Ambetter (Centene)

Centene's Ambetter runs as state-branded plans (Superior, Sunshine, Peach State and others), the process is published per state. Its sharpest rule: claim-payment disagreements are NOT appeals at all; they go through a separate claim dispute process first. From Ambetter (Centene)'s published pages, written for health care providers (Texas plan page) and members; each is listed below with its date. It is brand-level and applies to Ambetter of North Carolina Inc. in North Carolina the same as to every other Ambetter (Centene) entity in the file.

| Dispute | Route |
| --- | --- |
| Medical necessity denial | Appeal, 180 calendar days |
| Claims payment disagreement | NOT an appeal: 'the provider must follow the process for claim reconsideration or claim dispute … prior to filing a Complaint.' |

##### Operational facts from the same policy

- Medical-necessity appeal window: 180 calendar days

- Standard resolution clock: 30 calendar days

- Expedited appeal clock: 1 working day / 72 hours from complete information

- Submission (Texas plan): Complaints Department, 5900 E. Ben White Blvd., Austin, TX 78741 · Fax 1-866-683-5369 , Texas plan's address — each state plan publishes its own.

- Member appeal window: 180 calendar days, orally or in writing , Member-side confirmation of the 180-day window; also confirms the 30-day resolution clock ('shall not exceed 30 calendar days from the date Ambetter receives the appeal') and the expedited 1-working-day / 72-hour-written clock.

- Member APPEALS address differs from the complaints address: Appeals Department, 5900 E Ben White Blvd., Austin, TX 78741 · Fax 1-866-918-2266 , Same street address as the Complaints Department but a different fax: appeals go to 1-866-918-2266, grievances/complaints to 1-866-683-5369. The plan page's complaints fax is not the appeals fax.

- External review via MAXIMUS: four months from the final internal decision; standard decided ≤45 days, expedited ≤72 hours , Route: Externalappeal.com, fax 1-888-866-6190, or mail to MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534. Matches the federal 4-month right this site publishes.

Sources: [Ambetter (Centene), "Grievance and Appeals (Ambetter from Superior HealthPlan, Texas)"](https://www.ambetterhealth.com/en/tx/provider-resources/manuals-and-forms/grievance-appeals/) , quoted, not paraphrased; audience: health care providers (Texas plan page); checked 2026-11-05. [Ambetter (Centene), "Appeals and Grievances Guide (Ambetter from Superior HealthPlan, Texas — member guide, last updated December 2024)"](https://www.ambetterhealth.com/content/dam/centene/Sunshine/Ambetter/PDFs/AMB-TX-Appeals-Grievances-Guide.pdf) , quoted, not paraphrased; audience: members; checked 2026-11-05. Brand-level policy, applied here because Ambetter of North Carolina Inc. is an Ambetter (Centene) entity. Your own denial letter and plan documents govern your specific case.

## Questions

##### Is Ambetter of North Carolina Inc.'s denial rate in North Carolina high?

12.2% against a national average of 15.7% across the plans in this dataset. It is at or below average. A denial rate describes the insurer, not the merits of your claim.

##### How many people appealed an Ambetter of North Carolina Inc. denial in North Carolina, and how many won?

1,764 internal appeals were filed against 708,961 denials, and 52.38% of them were overturned (924 claims). How many went on to independent external review is not on the record for Ambetter of North Carolina Inc. in North Carolina, that is the absence stated at the top of this page and sourced at the foot of it.

##### How does Ambetter of North Carolina Inc. compare with other insurers in North Carolina?

Of the 5 insurers in North Carolina with a reported denial rate, Ambetter of North Carolina Inc. ranks 5 highest at 12.2%. The highest in North Carolina is AmeriHealth Caritas North Carolina, Inc. at 26.2%; the lowest is Ambetter of North Carolina Inc. at 12.2%.

##### What does Ambetter of North Carolina Inc. deny most often in North Carolina?

Referral required, 232,527 claims, 17.6% of this issuer's categorized denials, against 9.6% nationally. This is the denial-reason mix; the federal file does not report overturn rates by reason.

##### How long do I have to appeal an Ambetter of North Carolina Inc. denial in North Carolina?

Generally 180 days from the date on the denial notice to file the internal appeal, then generally four months from the final internal denial to request independent external review. Expedited review, decided in about 72 hours, is available where delay would seriously jeopardize your health. Those timeframes are federal, so they are identical for every insurer reporting in North Carolina, Ambetter of North Carolina Inc. included, what varies by state is who runs the independent review at the end. Your own denial letter states the deadlines that govern your plan; that letter is the authority.

##### Does appealing an Ambetter of North Carolina Inc. denial in North Carolina cost anything?

The internal appeal to Ambetter of North Carolina Inc. is free. External review is free under the HHS-administered federal process; where an issuer uses a contracted independent review organization or a state process, any fee is capped at $25 per review. Nobody in North Carolina can be charged more than that to file one.

##### Can Ambetter of North Carolina Inc. ignore an external review decision in North Carolina?

No, and that is the whole point of the stage. External review decisions are binding on the plan by law. The count is the one this page names as absent for Ambetter of North Carolina Inc. in North Carolina, so none is printed for it, an absent figure is not a count of none.

Ambetter of North Carolina Inc. sits at 12.2% in North Carolina against 15.7% nationally, and that is the whole of what this page can honestly tell you about your own claim. We are not going to tell you that you will win. This page prints the insurer's own reported numbers whichever way they fall. If what it says does not match the letter in your hand, write to us and we will correct the page.

Axion Labs · hello@getaxionlabs.com

[Get my Appeal Kit, $29](/appeal-kit)
Everything you need for your Ambetter of North Carolina Inc. appeal in North Carolina: your two deadlines, the argument that fits your denial reason, the letters, a brief for your doctor on what the reviewer checks, and the external review request. One payment. No subscription. No cut of your claim. Opens on screen the moment you pay. 14-day refund, no questions, one email to hello@getaxionlabs.com.

Where these numbers come from The Ambetter of North Carolina Inc. figures on this page, the 12.2% denial rate, the 708,961 denials, are this issuer’s own reported rows in that file. CMS did not report an external-review figure for Ambetter of North Carolina Inc. in North Carolina in the plan-year 2027 release of the Transparency in Coverage file, which is why no external-review count appears above.

Counts: [CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain](https://data.healthcare.gov/) . Rights and timeframes: [29 CFR 2560.503-1](https://www.ecfr.gov/current/title-29/section-2560.503-1) (180 days, and your free right to the claim file) and [45 CFR 147.136](https://www.ecfr.gov/current/title-45/section-147.136) (4 months, and what qualifies), explained at [HealthCare.gov](https://www.healthcare.gov/appeal-insurance-company-decision/external-review/) . Expedited review is decided in about 72 hours under both sections.

Reading either regulation from a script rather than a browser: eCFR answers automated fetches with a challenge page, so the same two sections are mirrored as government PDFs at [govinfo.gov (29 CFR 2560.503-1)](https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol9/pdf/CFR-2024-title29-vol9-sec2560-503-1.pdf) and [govinfo.gov (45 CFR 147.136)](https://www.govinfo.gov/content/pkg/CFR-2024-title45-vol2/pdf/CFR-2024-title45-vol2-sec147-136.pdf) .

This page presents federal statistics and a general description of appeal rights created by federal law. It is not legal, medical, or insurance advice, and no outcome is guaranteed. Your denial letter and plan documents govern your specific case. Free help is available from your state's Consumer Assistance Program and from the federal Marketplace at HealthCare.gov.

Problem solved: You have both dates for your Ambetter of North Carolina Inc. notice, you know that North Carolina runs the external review itself, and you have the letter, free, on this screen, tonight.

## The pages that answer the next question

- [Every insurer reporting in North Carolina](/states/north-carolina) , the state's own row, the 5 companies filing there, and the North Carolina insurance department's consumer number, read at source.

- [Ambetter denial rate](/company/ambetter) , Ambetter of North Carolina Inc. is the North Carolina one; the brand's national rate is 11.4% across 18,851,206 claims in 3 states, and it is not the same in any two of them.

- [AmeriHealth Caritas Florida, Inc. in Florida](/insurers/amerihealth-caritas-florida-inc--fl) , 17.8% of in-network claims denied, 233,629 of them, the neighboring record in this file.

- [AmeriHealth Caritas Indiana Inc in Indiana](/insurers/amerihealth-caritas-indiana-inc--in) , the neighboring record in this file; CMS reported no usable denial count for it.

- [AmeriHealth Caritas Louisiana, Inc. in Louisiana](/insurers/amerihealth-caritas-louisiana-inc--la) , the neighboring record in this file; CMS reported no usable denial count for it.

- [If your employer pays the claims itself](/self-funded-denial) , then Ambetter of North Carolina Inc. is only administering the plan, your state's external review has no power over the denial, and the route is federal. It is the first question our own calculator asks. 5 insurers report in North Carolina; whether your plan is one of theirs at all is what that page settles.

- [If it was refused before the treatment](/prior-authorization-denied) , a prior-authorization refusal from Ambetter of North Carolina Inc. runs on the same two federal clocks as a denied claim, and it can be appealed while the treatment is still ahead of you. 5,857,465 in-network claims were denied in North Carolina in this release; a refusal before the treatment is not counted among them and is appealed the same way.

- [Before you pay a lawyer](/before-you-call-a-lawyer) , two free appeals run before anyone bills you by the hour, and Ambetter of North Carolina Inc. has to hand you the claim file for nothing under 29 CFR 2560.503-1. Free help in North Carolina starts with the state consumer line printed on that state's page.

- [All 152 insurer-state records](/insurers) , the whole table, ranked, with Ambetter of North Carolina Inc. in it and the 5 that file in North Carolina beside it.

Your dates are ready. [Write the letter, free](/appeal-letter)

## The two federal clocks

The clock your letter has to describe, in actual dates Whatever else is on the page, these two dates are the page. You have 180 days from the date on your denial notice to file the internal appeal, and then 4 months from the final internal denial to ask for an independent external review. If waiting would seriously jeopardize your health you can ask for both to be expedited, decided in about 72 hours . Both timeframes are federal, not your insurer's choice, 29 CFR 2560.503-1 ( PDF ) and 45 CFR 147.136 ( PDF ), in plain English at HealthCare.gov , and your own denial letter states the ones that govern your plan. The PDFs are the same sections on govinfo.gov, which serves them without a challenge page, so an automated reader can check these two dates as easily as you can.

## How rare the second appeal is

You are not alone, measured rather than said: 83,907,852 in-network claims were denied in a single plan year, and only 4,918 of them, one in 17,061, ever reached the independent review stage. Of the ones that did, 22.2% (1,092 of 4,918; interval 22.2-23.8% for counts CMS withheld; 32.6% without SelectHealth) were overturned.

## What is free here, and what the one paid thing costs

Denied a claim? Insurers upheld 165,863 of the 262,982 internal appeals counted in 2024, 63.1% ( KFF ). The win is at independent external review, and the only way to arrive there is to run the internal stage on time, in the right order, with the record intact. That sequence is what the Appeal Kit is. Get my Appeal Kit, $29 One payment. No subscription. No cut of your claim. Opens on screen the moment you pay. 14-day refund, no questions, one email to hello@getaxionlabs.com. Get my Appeal Kit, $29 Everything you need for your appeal: your two deadlines, the argument that fits your denial reason, the letters, a brief for your doctor on what the reviewer checks, and the external review request. One payment. No subscription. No cut of your claim. Opens on screen the moment you pay. 14-day refund, no questions, one email to hello@getaxionlabs.com.

## What we will not pretend

What we will not pretend. We cannot overturn your denial. Only your plan, or an independent reviewer, can do that. We cannot make your plan cover a service it genuinely excludes. We cannot guarantee external review applies to your denial. It covers medical judgment, experimental or investigational determinations, and rescission, a purely administrative denial may not qualify, and we say so on those pages rather than selling you past it. We have no customer testimonials and publish none. Our evidence is the federal dataset and the regulation cites, both of which you can check.

## Every page on this site

Home Start here Insurers By company States Denial reasons Use cases How to appeal Ranked by denial rate The external-review gap Write the letter, free Deadline calculator Self-funded plan? Prior authorization denied Medicare WISeR denial Denial code CO-50 Before you call a lawyer Attorney for a denied claim Your denial letter United Healthcare denying claims Time limits on a claim Appeal a Medicare denial About Editorial policy How we compare Privacy Terms For machines: llms.txt openapi.json changes.json the composed answer this page as markdown

## Which release these figures are

Which release these figures are Every number on this page is the plan-year 2027 Transparency in Coverage file, issued October 22, 2026, covering plan-year 2025 claims. This is the newest plan year CMS has published: there is no Transparency in Coverage file for a plan year after 2027. The dataset list is at data.healthcare.gov . A test in this site’s build fetches that list on every run and fails if CMS publishes a plan year we have not acknowledged here. Every earlier release, plan-year 2024, plan-year 2025, plan-year 2026, is kept alongside it so the record is visible rather than a single year’s snapshot; /about says what changed between them. From the plan-year 2024 release to the plan-year 2026 release, external reviews filed went from 2,336 to 5,881. Overturned reviews went from 32.8% in the plan-year 2026 release to 22.2% in plan-year 2027, or from 32.6% to 32.6% without SelectHealth. We do not compare filed or overturned counts across plan-years 2026 and 2027. Some issuers may have counted pre-service appeals in their 2026 cells.

## Where these numbers come from

Where these numbers come from Counts: CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain . Rights and timeframes: 29 CFR 2560.503-1 (180 days, and your free right to the claim file) and 45 CFR 147.136 (4 months, and what qualifies), explained at HealthCare.gov . Expedited review is decided in about 72 hours under both sections. Reading either regulation from a script rather than a browser: eCFR answers automated fetches with a challenge page, so the same two sections are mirrored as government PDFs at govinfo.gov (29 CFR 2560.503-1) and govinfo.gov (45 CFR 147.136) .

## Who publishes this

Denial Facts publishes federal data about health insurance claim denials. We are independent: not affiliated with, endorsed by, or acting for any insurer, government agency, or review organization. We are not a law firm, a medical provider, or an insurance producer, and nothing here is legal, medical, or insurance advice. Data: CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain. Figures cover individual-market Qualified Health Plans on the federal Exchange and come from the plan-year 2027 release, issued October 22, 2026, covering plan-year 2025 claims. This is the newest plan year CMS has published: there is no Transparency in Coverage file for a plan year after 2027. See where the data comes from .

## Sources

- CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain: https://data.healthcare.gov/
- 29 CFR 2560.503-1 (180 days, and your free right to the claim file): https://www.ecfr.gov/current/title-29/section-2560.503-1
- 45 CFR 147.136 (4 months, and what qualifies): https://www.ecfr.gov/current/title-45/section-147.136
- HealthCare.gov on external review: https://www.healthcare.gov/appeal-insurance-company-decision/external-review/

Cite: Axion Labs — Denial Facts, "Ambetter of North Carolina appeal form and deadline", https://denialfacts.com/insurers/ambetter-of-north-carolina-inc--nc (checked 2026-11-04). free to quote with the URL.