North Dakota law sets deadlines and limits health plan approval reviews

Review organizations must make their prior authorization rules easy to find and understand. This applies to organizations that review prior authorization requests for the health benefit plans described in the law. The website must include written clinical criteria in plain, ordinary language. Before a new or amended rule takes effect, the organization must update its website and give contracted providers at least 60 days' written notice. The website must be updated before a new or amended rule takes effect.

Review organizations must follow decision deadlines and appeal rules. These rules apply when an organization requires prior authorization for a health care service. The appeal-review rules do not apply to reviews under sections 26.1-36-44 and 26.1-36-46. For routine requests, the organization must decide within seven calendar days after receiving all needed information; if requested information is not provided within 14 calendar days after a written request, it may deny the request. For urgent requests, it must decide within 72 hours after receiving all needed information. A licensed physician or pharmacist with experience treating the condition must make a denial. Appeals generally go to an experienced physician who was not involved in the denial; a qualified pharmacist or physician may review drug appeals. The appeal-review rules have stated exceptions. The decision periods begin when the organization receives all information needed to complete its review.

Review organizations may not require prior approval for emergency care or certain opioid treatment. The emergency limits apply to emergency transport and care for an emergency medical condition. The treatment limit applies to medication-assisted treatment for opioid use disorder. The emergency rule covers prehospital transport and emergency care for an emergency medical condition; medical necessity cannot depend on whether the provider is in the plan's network. Patients or providers have at least two business days after emergency care or admission to give notice. Immediate follow-up or post-stabilization emergency services must be approved or denied within two business days after a request; otherwise they are approved. The treatment rule covers medication-assisted treatment for opioid use disorder. The two-business-day decision period for immediate follow-up or post-stabilization services starts when the organization receives the request.

The law protects some existing approvals when a person changes plans or approval rules change. These protections apply to people with prior authorization who move to a new plan or whose plan changes coverage or approval criteria. A new plan must honor a documented prior approval for at least the first 60 days only if the service is covered under the new plan; the enrollee or provider must submit documentation under the new plan's procedures. A change in coverage or approval criteria generally does not affect a person already approved for the service until the next plan year, with an exception for drugs or devices deemed unsafe or withdrawn by the FDA or manufacturer. An organization must continue an approval when a person changes products within the same insurance company if the service is covered by the new plan. A new plan must honor a qualifying prior approval for at least the first 60 days of coverage; protections from changed approval rules generally last through the rest of the plan year.

Review organizations must report prior authorization data, and lawmakers must consider two studies. The annual reports are required from prior authorization review organizations. The studies concern public employee plan requirements and electronic requests for nonurgent and emergency services. By September 1 each year, organizations must report the previous calendar year's request totals, decisions, appeals, reasons for denials, and submission methods; the report must be available online. During the 2025–26 interim, legislative management must consider studies of public employee plan requirements and electronic submission of requests and medical records. The first study includes commercial plan data and stakeholder input; both studies report findings and recommendations to the 70th Legislative Assembly. Annual reports are due by September 1 for the previous calendar year. The studies take place during the 2025–26 interim and report to the 70th Legislative Assembly.