North Dakota Administrative Code
Title 45 - Insurance, Commissioner of
Article 45-06 - Accident and Health Insurance
Chapter 45-06-10 - Utilization Review
Section 45-06-10-02 - Subsequent determination after initial appeal

1. After an initial appeal to reverse a determination regarding hospital, medical, or other health care services is unsuccessful, a subsequent determination which may result in denial of third-party reimbursement or denial of precertification for service must include the evaluation, findings, and concurrence of a physician or licensed practitioner trained in the relevant specialty to make a final determination that care provided or to be provided was, is, or may be medically inappropriate.

2. A physician or licensed practitioner must hold a valid, current professional license issued by an appropriate professional board.

3. Compensation of a physician or licensed practitioner giving an opinion in regard to any determination under subsection 1 may not be dependent in any way upon the result of the final determination.