North Dakota Century Code Title 26.1. Insurance § 26.1-36.12-01. Definitions

1. “Adverse determination” means a decision by a prior authorization review organization relating to an admission, extension of stay, or health care service that is partially or wholly adverse to the enrollee, including a decision to deny an admission, extension of stay, or health care service on the basis it is not medically necessary.

2. “Appeal” means a formal request, either orally or in writing, to reconsider an adverse determination regarding an admission, extension of stay, or health care service.

3. “Authorization” means a determination by a prior authorization review organization that a health care service has been reviewed and, based on the information provided, satisfies the prior authorization review organization's requirements for medical necessity and appropriateness, and payment will be made for that health care service.

4. “Clinical criteria” means the written policies, written screening procedures, drug formularies or lists of covered drugs, determination rules, determination abstracts, clinical protocols, practice guidelines, medical protocols, and any other criteria or rationale used by the prior authorization review organization to determine the necessity and appropriateness of health care services.

5. “Emergency health care services” means health care services, supplies, or treatments furnished or required to screen, evaluate, and treat an emergency medical condition.

6. “Emergency medical condition” means a medical condition that manifests itself by symptoms of sufficient severity which may include pain and that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of medical attention to result in placing the individual's health in jeopardy, impairment of a bodily function, or dysfunction of any body part.

7. “Enrollee” means an individual who has contracted for or who participates in coverage under a policy for that individual or that individual's eligible dependents.

8. “Health care services” means health care procedures, treatments, or services provided by a licensed facility or provided by a licensed physician or within the scope of practice for which a health care professional is licensed. The term includes the provision of pharmaceutical products or services or durable medical equipment.

9. “Medically necessary” as the term applies to health care services means health care services a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is:

10. “Medication-assisted treatment” means the use of medications, commonly in combination with counseling and behavioral therapies, to provide a comprehensive approach to the treatment of substance use disorders. United States food and drug administration-approved medications used to treat opioid addiction include methadone and buprenorphine, alone or in combination with naloxone and extended-release injectable naltrexone. Types of behavioral therapies include individual therapy, group counseling, family behavior therapy, motivational incentives, and other modalities.

11. “Policy” means a health benefit plan as defined in section 26.1-36.3-01. The term does not include medical assistance or the public employees retirement system uniform group insurance program plans under chapter 54-52.1.

12. “Prior authorization” means the review conducted before the delivery of a health care service, including an outpatient health care service, to evaluate the necessity, appropriateness, and efficacy of the use of health care services, procedures, and facilities, by a person other than the attending health care professional, for the purpose of determining the medical necessity of the health care services or admission. The term includes a review conducted after the admission of the enrollee and in situations in which the enrollee is unconscious or otherwise unable to provide advance notification. The term does not include a referral or participation in a referral process by a participating provider unless the provider is acting as a prior authorization review organization.

13. “Prior authorization review organization” means a person that performs prior authorization for:

14. “Urgent health care service” means a health care service for which, in the opinion of a health care professional with knowledge of the enrollee's medical condition, the application of the time periods for making a nonexpedited prior authorization might: