N.D. Cent. Code § 26.1-36.12-01 Definitions
26.1-36.12-01. Definitions
As used in this chapter:
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:
a. In accordance with generally accepted standards of medical practice;
b. Clinically appropriate in terms of type, frequency, extent, site, and duration; and
c. Not primarily for the economic benefit of the health plans and purchasers or for
the convenience of the patient, treating physician, or other health care provider.
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:
a. An employer with employees in the state who are covered under a policy;
b. An insurer that writes policies;
c. A preferred provider organization or health maintenance organization; or
d. Any other person that provides, offers to provide, or administers hospital,
outpatient, medical, prescription drug, or other health benefits to an individual
treated by a health care professional in the state under a policy.
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:
a. Jeopardize the life or health of the enrollee or the ability of the enrollee to regain
maximum function; or
b. Subject the enrollee to pain that cannot be managed adequately without the care
or treatment that is the subject of the prior authorization review.