Health Insurance Benefit Coverage Law Summaries
North Dakota, Health Insurance Benefit Coverage Law Summaries
North Dakota's mandated health care law is located in the North Dakota Century Code at Titles 26.1 and 54. Coordination of benefits provisions are located in the North Dakota Administrative Code at Title 45, Article 48.
DEFINITIONS
A “small employer” is any person, firm, corporation, partnership, or association that is actively engaged in business that on at least half (50 percent) of its working days during the preceding calendar quarter employed at least three but no more than 25 eligible employees, the majority of whom are employed in North Dakota. Companies that are affiliated companies or eligible to file a combined tax return for the state are considered one employer (Sec. 26.1-36.3-01, as amended by H. 1178, L. 1999, effective August 1, 1999).
“Utilization review” is a system for prospective and concurrent review of the necessity and appropriateness in the allocation of health care resources and services given or proposed to be given to an individual within North Dakota. Utilization review does not include elective requests for clarification of coverage (Sec. 26.1-26.4-02, as amended by H. 1178, L. 1999, effective August 1, 1999).
“Utilization review agent” is any person or entity performing utilization review, except an agency of the federal government or an agent acting on behalf of the federal government, but only to the extent that the agent is providing services to the federal government (Sec. 26.1-26.4-02, as amended by H. 1178, L. 1999, effective August 1, 1999).
WHAT THE EMPLOYER MUST DO
North Dakota does not require employers to provide health insurance for their employees. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.
Mental health coverage.- An insurance company, nonprofit health service corporation, or health maintenance organization may not deliver, issue, execute, or renew any health insurance policy or health service contract on a group or blanket or franchise or association basis unless the policy or contract provides benefits, of the same type offered under the policy or contract for other illnesses, for health services to any person covered under the policy or contract, for the diagnosis, evaluation, and treatment of mental disorder and other related illness, which benefits meet or exceed the benefits outlined below (Sec. 26.1-36-09, as amended by S. 2213, L. 1999, effective August 1, 1999).
The benefits must be provided for inpatient treatment, treatment by partial hospitalization, outpatient treatment, and, effective August 1, 1997, residential treatment. In the case of benefits provided for inpatient treatment, the benefits must be provided for a minimum of 60 days of covered services in any calendar year if provided by a hospital licensed by the state of North Dakota offering treatment for the prevention or cure of mental disorders or other related illnesses (Sec. 26.1-36-09, as amended by S. 2213, L. 1999, effective August 1, 1999).
In the case of benefits provided for partial hospitalization or residential treatment, the benefits must be provided for a minimum of 120 days of covered services in any calendar year if provided by a hospital licensed by the state of North Dakota or by a licensed regional human service center offering treatment for the prevention or cure of mental disorders or other related illnesses (Sec. 26.1-36-09, as amended by S. 2213, L. 1999, effective August 1, 1999).
Benefits must be provided for a combination of inpatient hospitalization, partial hospitalization, and residential treatment (Sec. 26.1-36-09, as amended by S. 2213, L. 1999, effective August 1, 1999).
In the case of benefits provided for outpatient treatment, the benefits must be provided for a minimum of 30 hours for covered services in any calendar year if the treatment services are provided within the scope of licensure by a nurse who holds advanced licensure with a scope of practice within mental health or if the diagnosis, evaluation, and treatment services are provided within the scope of licensure by a licensed physician, a licensed psychologist who is eligible for listing on the National Register of Health Service Providers in psychology, or a licensed independent clinical social worker (Sec. 26.1-36-09, as amended by S. 2213, L. 1999, effective August 1, 1999).
Dependent care coverage.- All individual and group health insurance policies providing coverage on an expense-incurred basis and individual and group service or indemnity type contracts issued by a nonprofit corporation which provide coverage for a family member of the insured or subscriber must, as to the family members' coverage, also provide that the health insurance benefits applicable for children are payable with respect to a newly born child of the insured or subscriber from the moment of birth and are also payable from the date of physical placement by a licensed child placement agency or by the birth parent with respect to an adopted child (Sec. 26.1-36-07, as amended by Ch. 287, L. 1995).
The coverage for newly born children and for children placed for adoption by a licensed child placement agency or by the birth parent consists of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities (Sec. 26.1-36-07, as amended by Ch. 287, L. 1995).
An individual or group health insurance policy that provides coverage for a dependent child of an employee or other member of the covered group must provide such coverage up to a limiting age of 22 years of age, if the dependent child physically resides with the employee or other member and is chiefly dependent upon the employee or member for support and maintenance (Sec. 26.1-36-22, as amended by Ch. 246, L. 1995).
Disabilities.- An individual or group health insurance policy which provides that coverage for a dependent child of an employee or other member of the covered group terminates upon attainment of the limiting age for dependent children specified in the policy does not operate to terminate the coverage of a dependent child while the child is a full-time student and has not attained the age of 26 years, or while the child is and continues to be both incapable of self-sustaining employment by reason of mental retardation or physical disability and chiefly dependent upon the employee or member for support and maintenance (Sec. 26.1-36-22, as amended by Ch. 246, L. 1995).
Marital status of parent.- No insurer may deny enrollment of a child under the health coverage of the child's parent on the grounds that (Sec. 26.1-36.5-02):
the child was born out of wedlock;
the child is not claimed as a dependent on the parent's federal income tax return; or
the child does not reside with the parent or in the insurer's service area.
Small employers.- A standard small employer health benefit plan must provide coverage for recommended immunizations and well child visits for a covered person from birth to the age of five years (Sec. 26.1-36-09.4).
Substance abuse coverage.- An insurance company, nonprofit health service corporation, or health maintenance organization may not deliver, issue, execute, or renew any health insurance policy or health service contract on a group, blanket, franchise, or association basis unless the policy or contract provides benefits, of the same type offered under the policy or contract for other illnesses, for health services to any individual covered under the policy or contract, for the diagnosis, evaluation, and treatment of alcoholism, drug addiction, or other related illness, which benefits meet or exceed the benefits outlined below (Sec. 26.1-36-08(1), as amended by S. 2210, L. 2003).
The benefits must be provided for inpatient treatment, treatment by partial hospitalization, and outpatient treatment. In the case of benefits provided for inpatient treatment, the benefits must be provided for a minimum of 60 days of services in any calendar year. Services provided under this subdivision must be provided by an addiction treatment program licensed under Ch. 50-31 (Sec. 26.1-36-08(2)(a), as amended by S. 2210, L. 2003).
In the case of benefits provided for partial hospitalization, the benefits must be provided for a minimum of 120 days of covered services in any calendar year. Services provided under this subdivision must be provided by an addiction treatment program licensed under Ch. 50-31. For services provided in regional human service centers, charges must be reasonably similar to the charges for care provided by hospitals as defined in this subsection (Sec. 26.1-36-08(2)(b), as amended by S. 2210, L. 2003).
Benefits may also be provided for a combination of inpatient and partial hospitalization treatment (Sec. 26.1-36-08(2)(c), as amended by S. 2210, L. 2003).
In the case of benefits provided for outpatient treatment, the benefits must be provided for a minimum of 20 visits for covered services in any calendar year, provided the diagnosis, evaluation, and treatment services are provided within the scope of licensure by a licensed physician, a licensed psychologist who is eligible for listing on the National Register of Health Service Providers in psychology, or the treatment services are provided within the scope of licensure by a licensed addiction counselor. The insurance company, nonprofit health service corporation, or health maintenance organization may not establish a deductible or a copayment for the first five visits in any calendar year, and may not establish a copayment greater than 20 percent for the remaining visits (Sec. 26.1-36-08(2)(d), as amended by S. 2210, L. 2003).
Alternative group health policy and health service contract substance abuse coverage.- As an alternative to the substance abuse coverage required under Sec. 26.1-36-08(2) (above), an insurance company, a nonprofit health service corporation, or an HMO may provide substance abuse coverage under this section. The provisions of Sec. 26.1-36-08 apply to this alternative, except (Sec. 2, S. 2210, L. 2003):
in addition to the inpatient treatment, treatment by partial hospitalization, and outpatient treatment coverage required under Sec. 26.1-36-08, the coverage must include residential treatment.
in the case of coverage for inpatient treatment, the benefits must be provided for a minimum of 45 days of services covered under this section and Sec. 26.1-36-09 in any calendar year.
for the purposes of computing the period for which benefits are payable for a combination of inpatient and partial hospitalization, no more than 23 days of inpatient treatment benefits required under item (1) just above may be traded for treatment by partial hospitalization.
in the case of coverage for residential treatment, the benefits must be provided for a minimum of 60 days of services covered under this section in any calendar year. This residential treatment must be provided by an addiction treatment program licensed under Ch. 50-31. If an individual receiving residential treatment services requires more than 60 days of residential treatment services, unused inpatient treatment benefits provided for under item (2) just above may be traded for residential treatment benefits. For the purpose of computing the period for which benefits are payable, each day of inpatient treatment is equivalent to two days of treatment by a residential treatment program, provided that no more than 23 days of inpatient treatment benefits required by this section may be traded for residential treatment benefits required under this section.
Coordination of benefits.- An employer or the insurer, managed care plan, or third-party administrator that manages a health benefit plan for an employer may share the payment of expenses with another benefit plan sponsored by another employer, with the government through Medicare benefits, or with another type of insurance company through automobile or homeowners' insurance (subrogation). To determine which plan has primary responsibility for payment, coordination of benefits (COB) language specifies the order of benefit payments. Preserving cost management initiatives, such as deductibles and coinsurance, is known as maintenance of benefits. The National Association of Insurance Commissioners (NAIC) has established model guidelines for COB which many states apply to insurance companies, HMOs, or other health care benefit providers. Self-insured employee benefit plans are not required to adopt coordination of benefits language; however, most self-insured health plans do specify how they will coordinate benefit payments with other plans.
The following types of plans must specify how benefits will be coordinated: group insurance, group subscriber contracts, uninsured arrangements of group or group-type coverages, group or group-type coverage through an HMO, and other prepayment, group practice, and individual practice plans, group-type contracts available to a membership in a particular organization or group if the individual does not have a right to maintain or renew the policy independent of continued employment with an employer, group or group-type excess hospital indemnity benefits exceeding $100 per day, group or group-type or individual “no fault ” and “fault” contracts, or Medicare or other governmental benefits. A plan shall not include: individual or family insurance or subscriber contracts, individual HMO coverage, individual or family coverage through prepayment, group practice, or individual practice plans, group or group-type hospital indemnity benefits of $100 per day or less, school accident-type coverages, or a state plan under Medicaid (North Dakota Administrative Code Title 45, Art. 48, Sec. 45-48-01.1).
Order of benefits.- The following priority applies when coordinating health benefit payments (North Dakota Administrative Code Sec. 45-48-01.1-03):
Employee/Dependent: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee, subscriber, or member before a plan or policy that covers the individual as a dependent;
Dependent Child/Birthday Rule: For a dependent child whose parents are not separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the parent whose birthday month and day is earlier in the calendar year. If both parents have the same birthday, benefits will be paid first by the plan that covered a parent for a longer period of time. If only one plan specifies the birthday rule and the other plan specifies priority based on the gender of the parents, benefits will be paid first according to the order of benefits specified in the plan without the birthday rule;
Dependent Child/Divorced or Separated Parents: For a dependent child whose parents are separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the custodial parent, second by the plan of the spouse of the custodial parent, and third by the plan of the noncustodial parent. If a court decree states that one of the parents is responsible for health care expenses of the child, benefits will be paid first by the plan of that parent. If the specific terms of the court decree state that the parents will share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules specified in the birthday rule;
Active/Inactive Employee: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee who is neither laid off or retired or as that person's dependent before a plan or policy that covers the individual as a laid-off or retired employee or dependent. If only one of the two plans specifies this rule, this standard is ignored;
Longer/Shorter Length of Coverage: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that has covered the individual as an employee, subscriber, or member for a longer period of time before a plan or policy that covered the individual for a shorter period of time;
Continuation Coverage: For an individual covered by two health benefit plans, HMOs, or health insurance policies, one of which is a COBRA continuation plan, benefits will be paid first by the plan that covers the individual as an employee, member, or subscriber or as the employee's dependent and second under the COBRA continuation coverage. If only one of the two plans specifies this rule, this standard is ignored; and
Excess Benefits: A complying plan may coordinate its benefits with a plan that is “excess” or “always secondary” or that uses an order of benefit determination provision that is inconsistent with that contained in this rule (called a noncomplying plan), on the following basis: if the complying plan is the primary plan, it must pay or provide its benefits on a primary basis. If the complying plan is the secondary plan, it must still pay or provide its benefits first, as the secondary plan. In such a situation, such payment is the limit of the complying plan's liability, except if the noncomplying plan does not provide the information needed by the complying plan to determine its benefits within a reasonable time after it is requested to do so, the complying plan may assume that the benefits of the noncomplying plan are identical to its own and pay its benefits accordingly. The complying plan must adjust any payments it makes based on such assumption when information becomes available about the actual benefits of the noncomplying plan. If the noncomplying plan pays less in benefits than it would have if the noncomplying plan paid or provided its benefits as the primary plan, the complying plan must advance an amount equal to such difference.
Maintenance of benefits.- A plan that pays benefits on a secondary basis may reduce benefits as long as the total paid is not more than allowable expenses (North Dakota Administrative Code Sec. 45-48-01.1-04).
Required language.- North Dakota makes available model provisions for use in group contracts (North Dakota Administrative Code Appendix A to Sec. 45-48-01).
Providers: Chiropractors.- No insurance company or health service corporation may deliver, issue, execute, or renew any health insurance policy or medical service contract that includes coverage of medical benefits on a group, blanket, franchise, or association basis unless the insurer makes available, at the option of the policyholder, coverage for services rendered and care administered by chiropractors licensed under North Dakota law (Sec. 26.1-36-06).
Preexisting conditions.- An insurer may impose a preexisting condition exclusion only if (Sec. 26.1-36.4-03, as amended by H. 1178, L. 1999, effective August 1, 1999):
The exclusion relates to a condition, regardless of the cause of the condition, for which medical diagnosis, care or treatment was recommended or received within the six-month period ending on the effective date of the person's coverage.
The exclusion extends for a period of not more than 12 months after the effective date of coverage. Effective August 1, 1999, a group policy may impose an 18-month preexisting condition to a late enrollee.
Small employers.- Group health insurance plans for small employers may deny health benefit coverage because of preexisting conditions if medical advice or treatment was recommended or received within six months immediately before the effective date of coverage or the insured was pregnant on the effective date of coverage. Coverage will not be excluded due to preexisting conditions for longer than 12 months after the effective date. If the insured is covered within 90 days of having other qualifying coverage, the new policy will credit the time covered under the previous contract or policy toward an exclusion for preexisting conditions. An insurance carrier that does not use preexisting condition limitations in any health benefit plan may impose a carrier waiting period (Sec. 26.1-36.3-06, as amended by H. 1178, L. 1999, effective August 1, 1999).
Pharmaceutical services: Open choice.- No third party payor, including a health care insurer, providing pharmacy services and prescription drugs to any beneficiary may (Sec. 26.1-36-12.2):
prevent a beneficiary from selecting the pharmacy or pharmacist of the beneficiary's choice to provide pharmaceutical goods and services, provided that pharmacist or pharmacy is licensed in North Dakota;
impose upon any beneficiary selecting a participating or contracting provider a copayment, fee, or other condition not equally imposed upon all beneficiaries in the plan selecting a participating or contracting provider; or
deny any pharmacy or pharmacist the right to participate as a preferred provider or contracting provider for any policy or plan, provided the pharmacist or pharmacy is licensed in North Dakota and accepts the terms of the third-party payor's contract.
Prescription drugs.- No insurance company or health service corporation may deliver, issue, execute, or renew any health insurance policy or medical service contract that includes coverage of medical benefits on a group, blanket, franchise, or association basis unless the insurer makes available, at the option of the policyholder, coverage of all drugs and medicines prescribed by the provider of health services (Sec. 26.1-36-06).
An insurance company, nonprofit health service corporation or HMO may not deliver, issue, execute or renew any health insurance policy, health service contract or evidence of coverage that provides prescription coverage on a group, blanket, franchise or association basis, unless the policy or contract provides, for any covered person born after December 31, 1962, coverage for medical foods and low protein modified food products determined by a physician to be medically necessary for the therapeutic treatment of an inherited metabolic disease. Coverage is not required for low protein modified food products in excess of $3,000 per year for an individual with an inherited metabolic disease of amino acid or organic acid (Sec. 26.1-36-09.7, as amended by S. 2374, L. 1999, effective August 1, 1999).
Mammograms.- An insurance company, nonprofit health service corporation, or health maintenance organization may not deliver, issue, execute, or renew any health insurance policy, health service contract, or evidence of coverage on an individual, group, blanket, franchise, or association basis unless the policy, contract, or evidence of coverage provides benefits, of the same type offered under the policy or contract for illnesses, for health services to any person covered under the policy or contract for (Sec. 26.1-36-09.1):
one baseline mammogram examination for each woman who is at least 35 but less than 40 years of age;
one mammogram examination every two years or more frequently if ordered by a physician for women who are at least 40 but less than 50 years of age;
one mammogram examination every year for women age 50 and over.
Coverage for mammograms must also be provided by North Dakota's uniform group insurance program (Sec. 54-52.1-04.4).
Coverage for mammograms need not be provided by individually guaranteed renewable supplemental, specified disease, long-term care, or other limited benefit policies (Sec. 26.1-36-09.1).
Breast reconstruction surgery.- An insurance company, nonprofit health service corporation, or HMO may not deliver, issue, execute, or renew any policy, service contract or evidence of coverage on a group basis unless the policy, contract, or evidence of insurance provides the benefit provisions of the federal Women's Health and Cancer Rights Act of 1998 (Sec. 26.1-36-09.11, as added by H. 1144, L. 2001).
Maternity benefits.- An insurance company, nonprofit health service corporation, or health maintenance organization may not deliver, issue, execute, or renew any health insurance policy, health service contract, or evidence of coverage that provides maternity benefits on an individual, group, blanket, franchise, or association basis unless the policy, contract, or evidence of coverage provides benefits, of the same type offered for illnesses, for health services to covered persons for (Sec. 1, S. 2043, L. 1997, effective August 1, 1997):
inpatient care for at least 48 hours for a mother and her newborn child following a normal vaginal delivery, and inpatient care for at least 96 hours following a caesarean section, without requiring the attending physician or health care provider to obtain authorization to care for a mother and her newborn child in the inpatient setting for this period of time;
inpatient care in excess of 48 hours following a vaginal delivery and 96 hours following a caesarean section if the stay is determined to be reasonable and medically necessary.
Coverage is not required for postdelivery inpatient care for a covered mother and her newborn child during the entire minimum time period required above if (Sec. 1, S. 2043, L. 1997, effective August 1, 1997):
the attending physician or health care provider, in consultation with the mother, decides to discharge the mother and her newborn child early; and
the mother and her newborn child meet the minimum medical criteria for discharge as recommended in the “Guidelines for Perinatal Care” prepared by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics.
Before February 1, 1998, every insurance company, nonprofit health service corporation, and HMO subject to the requirements described above must provide written notice of a material change in maternity benefits coverage under the new requirements to every affected insured (Sec. 2, S. 2043, L. 1997).
Complications of pregnancy.- No insurance company, nonprofit health service corporation, or health maintenance organization may deliver, issue, execute, or renew any health insurance policy, health service contract, or evidence of coverage on an individual, group, blanket, franchise, or association basis if the policy, contract, or evidence of coverage contains any exclusion, reduction, or other limitation as to coverage, deductibles, or coinsurance provisions, as to involuntary complications of pregnancy, unless the provisions apply generally to all benefits paid (Sec. 26.1-36-09.2).
This also applies to medical benefits coverage provided under North Dakota's uniform group insurance program (Sec. 54-52.1-04.5).
Small employers.- A standard small employer health benefit plan must provide coverage for prenatal care visits for a covered person (Sec. 26.1-36-09.4).
Prostate cancer screenings.- An insurance company, nonprofit health service corporation, or HMO may not deliver, issue, execute, or renew any health insurance policy, health service contract, or evidence of coverage on an individual, group, blanket, franchise, or association basis unless the policy, contract, or evidence of coverage provides an annual medically recognized diagnostic examination that includes a digital rectal examination and a prostate-specific antigen test for an asymptomatic male aged 50 and over, a black male aged 40 and over, and a male aged 40 or over with a family history of prostate cancer (Sec. 1, S. 2115, L. 1997, effective August 1, 1997).
Temporomandibular joint disorder.- Except for policies that only provide coverage for specified diseases, no policy or certificate of health, medical, hospitalization, or accident and sickness insurance, or a subscriber contract provided by a nonprofit health service corporation, preferred provider organization, or health maintenance organization, may be issued, renewed, continued, delivered, issued for delivery, or executed in North Dakota after January 1, 1990, unless the policy, certificate, plan, or contract specifically provides coverage for surgical and nonsurgical treatment of temporomandibular joint disorder and craniomandibular disorder. Coverage must be the same as that for treatment to any other joint in the body, and applies if the treatment is administered or prescribed by a physician or a dentist. Benefits for the coverage may be limited to a lifetime maximum of $10,000 per person for surgery, and $2,500 for nonsurgical treatment (Sec. 26.1-36-09.3, as amended by Ch. 290, L. 1995).
The temporomandibular joint disorder coverage described above must also be provided by North Dakota's uniform group insurance program (Sec. 54-52.1-04.6).
Dental care.- An insurance company, nonprofit health service corporation or HMO may not deliver, issue, execute or renew any health insurance policy, health service contract or evidence of coverage on a group basis unless it provides benefits for anesthesia and hospitalization for dental care provided to a covered individual who is a child under age nine, is severely disabled, or who has a medical condition and requires hospitalization or general anesthesia for dental care treatment (Sec. 1, H. 1452, L. 1999, effective August 1, 1999).
Utilization review: Certification of UR agents.- To promote delivery of quality health care in a cost-effective manner, assure that utilization review agents adhere to reasonable standards, foster coordination and cooperation between health care providers and UR agents, improve communication among all parties, and ensure that medical records are kept confidential, North Dakota requires UR agents to be certified annually and adhere to minimum standards (Secs. 26.1-26.4-01-26.1-26.4-05). Violations will be addressed by the Commissioner, who may order payment of a penalty fine or suspend or revoke the certification of the UR agent (Sec. 26.1-26.4-05).
Standards for UR agents.- Utilization review agents must meet the following standards (Sec. 26.1-26.4-04, as amended by S. 2184, L. 2003; and Sec. 26.1-26.4-04.1):
notification of a determination by the UR agent must be provided to the enrollee or other appropriate individual in accordance with 29 USC 1133 and the timeframes set forth in 29 CFR 2560.503-1;
determine the necessity or appropriateness of an admission, service, or procedure in accordance with a physician's guidelines or have a physician perform the review;
any notification of a determination not to certify an admission or service or procedure must include the information required by 29 USC 1133 and 29 CFR 2560.503-1;
maintain and make available a written description of the appeal procedure by which the enrolled individual or the provider of record may seek review of a determination by the UR agent. The appeal procedure must provide that: (a) on appeal, all determinations not to certify an admission, service, or procedure as being necessary or appropriate will be made by a physician in the same or a similar general specialty as typically manages the medical condition, procedure or treatment under discussion as mutually deemed appropriate; (b) UR agents will complete the appeals determinations in accordance with 29 USC 1133 and the timeframes for appeals set forth in CFR 2560.503-1; and (c) when an initial determination not to certify a health care service is made prior to or during an ongoing service requiring review, and the attending physician believes that the determination warrants immediate appeal, the attending physician will have an opportunity to appeal that determination over the telephone on an expedited basis. UR agents will provide for an expedited appeals process complying with 29 USC 1133 and 29 CFR 2560.503-1. Expedited appeals that do not resolve a difference of opinion may be resubmitted through the standard appeal process;
have staff available by toll-free telephone at least 40 hours per week during normal business hours;
have a telephone system capable of accepting or recording incoming telephone calls during other than normal business hours and respond to these calls within two working days;
protect the confidentiality of individual medical records;
employ currently licensed physicians or psychologists to make utilization review determinations;
allow a minimum of 24 hours after an emergency admission, service, or procedure for notification of the UR agent and request certification or continuing treatment for that condition;
when an initial appeal to reverse a determination is unsuccessful, a subsequent determination regarding hospital, medical, or other health care services provided or to be provided to a patient that may result in a denial of third-party reimbursement or a denial of precertification for that service must include the evaluation, findings, and concurrence of a physician trained in the relevant specialty to make a final determination that care provided or to be provided was, is, or may be medically inappropriate.
Compensation of insurance company employees.- In the business of insurance, it is an unfair practice to base the compensation of claims employees (or contracted claims personnel) on:
the number of policies canceled;
the number of times coverage is denied;
a quota limiting or restricting the number or volume of claims; or
an arbitrary quota or cap limiting or restricting the amount of claim payment without consideration to the merits of the claim.
Performance bonuses and incentives are included (Sec. 26.1-04-03, as amended by S. 2104 (L. 2009), enacted March 19, 2009, effective August 1, 2009).
WHO TO CONTACT
Contact the Insurance Commissioner at State Capitol, 5th Floor, 600 E. Boulevard Avenue, Bismarck, ND 58505-0320. Telephone: (701) 328-2440. Fax: (701) 328-4880.
<p>Contact the Insurance Commissioner at State Capitol, 5th Floor, 600 E. Boulevard Avenue, Bismarck, ND 58505-0320. Telephone: (701) 328-2440.</p>
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