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North Dakota Senate Bill SB2280

North Dakota 2025-2026 Regular Session

North Dakota Senate Bill SB2280 Compare Versions

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1-Sixty-ninth Legislative Assembly of North Dakota
2-In Regular Session Commencing Tuesday, January 7, 2025
3-SENATE BILL NO. 2280
4-(Senators Meyer, Barta, Bekkedahl, Cleary)
5-(Representatives Nelson, Warrey)
6-AN ACT to create and enact chapter 26.1-36.12 of the North Dakota Century Code, relating to prior
7-authorization for health insurance; to provide for a legislative management study; to provide for
8-a legislative management report; and to provide an effective date.
1+25.1180.04000
2+Sixty-ninth
3+Legislative Assembly
4+of North Dakota
5+Introduced by
6+Senators Meyer, Barta, Bekkedahl, Cleary
7+Representatives Nelson, Warrey
8+A BILL for an Act to create and enact chapter 26.1-36.12 of the North Dakota Century Code,
9+relating to prior authorization for health insurance; to provide for a legislative management
10+study; to provide for a legislative management report; and to provide an effective date.
911 BE IT ENACTED BY THE LEGISLATIVE ASSEMBLY OF NORTH DAKOTA:
10-SECTION 1. Chapter 26.1-36.12 of the North Dakota Century Code is created and enacted as
11-follows:
12+SECTION 1. Chapter 26.1-36.12 of the North Dakota Century Code is created and enacted
13+as follows:
1214 26.1-36.12-01. Definitions.
1315 As used in this chapter:
14-1."Adverse determination" means a decision by a prior authorization review organization relating
15-to an admission, extension of stay, or health care service that is partially or wholly adverse to
16-the enrollee, including a decision to deny an admission, extension of stay, or health care
17-service on the basis it is not medically necessary.
16+1."Adverse determination" means a decision by a prior authorization review organization
17+relating to an admission, extension of stay, or health care service that is partially or
18+wholly adverse to the enrollee, including a decision to deny an admission, extension of
19+stay, or health care service on the basis it is not medically necessary.
1820 2."Appeal" means a formal request, either orally or in writing, to reconsider an adverse
1921 determination regarding an admission, extension of stay, or health care service.
20-3."Authorization" means a determination by a prior authorization review organization that a
21-health care service has been reviewed and, based on the information provided, satisfies the
22-prior authorization review organization's requirements for medical necessity and
23-appropriateness, and payment will be made for that health care service.
24-4."Clinical criteria" means the written policies, written screening procedures, drug formularies or
25-lists of covered drugs, determination rules, determination abstracts, clinical protocols, practice
26-guidelines, medical protocols, and any other criteria or rationale used by the prior
27-authorization review organization to determine the necessity and appropriateness of health
28-care services.
22+3."Authorization" means a determination by a prior authorization review organization that
23+a health care service has been reviewed and, based on the information provided,
24+satisfies the prior authorization review organization's requirements for medical
25+necessity and appropriateness, and payment will be made for that health care service.
26+4."Clinical criteria" means the written policies, written screening procedures, drug
27+formularies or lists of covered drugs, determination rules, determination abstracts,
28+clinical protocols, practice guidelines, medical protocols, and any other criteria or
29+Page No. 1 25.1180.04000
30+ENGROSSED SENATE BILL NO. 2280
31+FIRST ENGROSSMENT
32+with House Amendments
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55+rationale used by the prior authorization review organization to determine the
56+necessity and appropriateness of health care services.
2957 5."Emergency health care services" means health care services, supplies, or treatments
3058 furnished or required to screen, evaluate, and treat an emergency medical condition.
31-6."Emergency medical condition" means a medical condition that manifests itself by symptoms
32-of sufficient severity which may include pain and that a prudent layperson who possesses an
33-average knowledge of health and medicine could reasonably expect the absence of medical
34-attention to result in placing the individual's health in jeopardy, impairment of a bodily function,
35-or dysfunction of any body part.
36-7."Enrollee" means an individual who has contracted for or who participates in coverage under a
37-policy for that individual or that individual's eligible dependents.
38-8."Health care services" means health care procedures, treatments, or services provided by a
39-licensed facility or provided by a licensed physician or within the scope of practice for which a
40-health care professional is licensed. The term includes the provision of pharmaceutical
41-products or serv ices or durable medical equipment. S. B. NO. 2280 - PAGE 2
42-9."Medically necessary" as the term applies to health care services means health care services
43-a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or
44-treating an illness, injury, disease, or its symptoms in a manner that is:
59+6."Emergency medical condition" means a medical condition that manifests itself by
60+symptoms of sufficient severity which may include pain and that a prudent layperson
61+who possesses an average knowledge of health and medicine could reasonably
62+expect the absence of medical attention to result in placing the individual's health in
63+jeopardy, impairment of a bodily function, or dysfunction of any body part.
64+7."Enrollee" means an individual who has contracted for or who participates in coverage
65+under a policy for that individual or that individual's eligible dependents.
66+8."Health care services" means health care procedures, treatments, or services
67+provided by a licensed facility or provided by a licensed physician or within the scope
68+of practice for which a health care professional is licensed. The term includes the
69+provision of pharmaceutical products or serv ices or durable medical equipment.
70+9."Medically necessary" as the term applies to health care services means health care
71+services a prudent physician would provide to a patient for the purpose of preventing,
72+diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is:
4573 a.In accordance with generally accepted standards of medical practice;
4674 b.Clinically appropriate in terms of type, frequency, extent, site, and duration; and
47-c.Not primarily for the economic benefit of the health plans and purchasers or for the
48-convenience of the patient, treating physician, or other health care provider.
49-10."Medication-assisted treatment" means the use of medications, commonly in combination with
50-counseling and behavioral therapies, to provide a comprehensive approach to the treatment of
51-substance use disorders. United States food and drug administration-approved medications
52-used to treat opioid addiction include methadone and buprenorphine, alone or in combination
53-with naloxone and extended-release injectable naltrexone. Types of behavioral therapies
54-include individual therapy, group counseling, family behavior therapy, motivational incentives,
55-and other modalities.
56-11."Policy" means a health benefit plan as defined in section 26.1 - 36.3 - 01. The te rm does not
57-include medical assistance or the public employees retirement system uniform group
58-insurance program plans under chapter 54 - 52.1.
59-12."Prior authorization" means the review conducted before the delivery of a health care service,
60-including an outpatient health care service, to evaluate the necessity, appropriateness, and
61-efficacy of the use of health care services, procedures, and facilities, by a person other than
62-the attending health care professional, for the purpose of determining the medical necessity of
63-the health care services or admission. The term includes a review conducted after the
64-admission of the enrollee and in situations in which the enrollee is unconscious or otherwise
65-unable to provide advance notification. The term does not include a referral or participation in
66-a referral process by a participating provider unless the provider is acting as a prior
67-authorization review organization.
68-13."Prior authorization review organization" means a person that performs prior authorization for:
75+c.Not primarily for the economic benefit of the health plans and purchasers or for
76+the convenience of the patient, treating physician, or other health care provider.
77+10."Medication assisted treatment" means the use of medications, commonly in
78+combination with counseling and behavioral therapies, to provide a comprehensive
79+approach to the treatment of substance use disorders. United States food and drug
80+administration-approved medications used to treat opioid addiction include methadone
81+and buprenorphine, alone or in combination with naloxone and extended-release
82+injectable naltrexone. Types of behavioral therapies include individual therapy, group
83+counseling, family behavior therapy, motivational incentives, and other modalities.
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115+11."Policy" means a health benefit plan as defined in section 26.1 - 36.3 - 01. The te rm does
116+not include medical assistance or the public employees retirement system uniform
117+group insurance program plans under chapter 54 - 52.1.
118+12."Prior authorization" means the review conducted before the delivery of a health care
119+service, including an outpatient health care service, to evaluate the necessity,
120+appropriateness, and efficacy of the use of health care services, procedures, and
121+facilities, by a person other than the attending health care professional, for the
122+purpose of determining the medical necessity of the health care services or admission.
123+The term includes a review conducted after the admission of the enrollee and in
124+situations in which the enrollee is unconscious or otherwise unable to provide advance
125+notification. The term does not include a referral or participation in a referral process
126+by a participating provider unless the provider is acting as a prior authorization review
127+organization.
128+13."Prior authorization review organization" means a person that performs prior
129+authorization for:
69130 a.An employer with employees in the state who are covered under a policy;
70131 b.An insurer that writes policies;
71132 c.A preferred provider organization or health maintenance organization; or
72-d.Any other person that provides, offers to provide, or administers hospital, outpatient,
73-medical, prescription drug, or other health benefits to an individual treated by a health
74-care professional in the state under a policy.
75-14."Urgent health care service" means a health care service for which, in the opinion of a health
76-care professional with knowledge of the enrollee's medical condition, the application of the
77-time periods for making a nonexpedited prior authorization might:
133+d.Any other person that provides, offers to provide, or administers hospital,
134+outpatient, medical, prescription drug, or other health benefits to an individual
135+treated by a health care professional in the state under a policy.
136+14."Urgent health care service" means a health care service for which, in the opinion of a
137+health care professional with knowledge of the enrollee's medical condition, the
138+application of the time periods for making a non-expedited prior authorization might:
78139 a.Jeopardize the life or health of the enrollee or the ability of the enrollee to regain
79140 maximum function; or
80-b.Subject the enrollee to pain that cannot be managed adequately without the care or
81-treatment that is the subject of the prior authorization review.
141+b.Subject the enrollee to pain that cannot be managed adequately without the care
142+or treatment that is the subject of the prior authorization review.
82143 26.1-36.12-02. Disclosure and review of prior authorization requirements.
83-1.A prior authorization review organization shall make any prior authorization requirements and
84-restrictions readily accessible on the organization's website to enrollees, health care S. B. NO. 2280 - PAGE 3
85-professionals, and the general public. Requirements include the written clinical criteria and be
86-described in detail using plain and ordinary language comprehensible by a layperson.
87-2.If a prior authorization review organization intends to implement a new prior authorization
88-requirement or restriction, or amend an existing requirement or restriction, the prior
89-authorization review organization shall:
144+1.A prior authorization review organization shall make any prior authorization
145+requirements and restrictions readily accessible on the organization's website to
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179+enrollees, health care professionals, and the general public. Requirements include the
180+written clinical criteria and be described in detail using plain and ordinary language
181+comprehensible by a layperson.
182+2.If a prior authorization review organization intends to implement a new prior
183+authorization requirement or restriction, or amend an existing requirement or
184+restriction, the prior authorization review organization shall:
90185 a.Ensure the new or amended requirement is not implemented unless the prior
91-authorization review organization's website has been updated to reflect the new or
92-amended requirement or restriction; and
186+authorization review organization's website has been updated to reflect the new
187+or amended requirement or restriction; and
93188 b.Provide contracted health care providers of enrollees written notice of the new or
94-amended requirement or amendment no fewer than sixty days before the requirement or
95-restriction is implemented.
189+amended requirement or amendment no fewer than sixty days before the
190+requirement or restriction is implemented.
96191 26.1-36.12-03. Personnel qualified to make adverse determinations.
97-A prior authorization review organization shall ensure all adverse determinations are made b y a
98-licensed physician or licensed pharmacist. The reviewing individual:
99-1.Must have experience treating patients with the condition or illness for which the health care
100-service is being requested; and
192+A prior authorization review organization shall ensure all adverse determinations are made
193+b y a licensed physician or licensed pharmacist. The reviewing individual:
194+1.Must have experience treating patients with the condition or illness for which the
195+health care service is being requested; and
101196 2.Shall make the adverse determination under the clinical direction of one of the prior
102-authorization review organization's medical directors who is responsible for the health care
103-services provided to enrollees.
197+authorization review organization's medical directors who is responsible for the health
198+care services provided to enrollees.
104199 26.1 - 36.12 - 04. Personnel qualified to review appeals.
105-1.A prior authorization review organization shall ensure all appeals are reviewed by a physician.
106-The reviewing individual:
200+1.A prior authorization review organization shall ensure all appeals are reviewed by a
201+physician . The reviewing individual:
107202 a.Shall possess a valid nonrestricted license to practice medicine .
108-b.Must be in active practice in the same or similar specialty as the physician who typically
109-manages the medical condition or disease for at least five consecutive years.
110-c.Must be knowledgeable of, and have experience providing, the health care services
111-under appeal.
112-d.May not receive any financial incentive based on the number of adverse determinations
113-made. This subdivision does not apply to financial incentives established between health
114-plan companies and health care providers.
203+b.Must be in active practice in the same or similar specialty as the physician who
204+typically manages the medical condition or disease for at least five consecutive
205+years .
206+c.Must be knowledgeable of, and have experience providing, the health care
207+services under appeal .
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239+d.May not receive any financial incentive based on the number of adverse
240+determinations made. This subdivision does not apply to financial incentives
241+established between health plan companies and health care providers.
115242 e.May not have been directly involved in making the adverse determination .
116243 f.Shall consider all known clinical aspects of the health care service under review,
117-including a review of all pertinent medical records provided to the prior authorization
118-review organization by the enrollee's health care provider, any relevant records provided
119-to the prior authorization review organization by a health care facility, and any medical
120-literature provided to the prior authorization review organization by the health care
121-provider.
122-2.A review of an adverse determination involving a prescription drug must be conducted by a
123-licensed pharmacist or physician who is competent to evaluate the specific clinical issues
124-presented in the review.
125-3.This section does not apply to reviews conducted under sections 26.1 - 36 - 44 and 26.1 - 36 - 46. S. B. NO. 2280 - PAGE 4
244+including a review of all pertinent medical records provided to the prior
245+authorization review organization by the enrollee's health care provider, any
246+relevant records provided to the prior authorization review organization by a
247+health care facility, and any medical literature provided to the prior authorization
248+review organization by the health care provider.
249+2.A review of an adverse determination involving a prescription drug must be conducted
250+by a licensed pharmacist or physician who is competent to evaluate the specific
251+clinical issues presented in the review.
252+3.This section does not apply to reviews conducted under sections 26.1 - 36 - 44 and
253+26.1 - 36 - 46.
126254 26.1 - 36.12 - 05. Prior authorization - Nonurgent circumstances.
127-1.If a prior authorization review organization requires prior authorization of a health care service,
128-the prior authorization review organization shall make a prior authorization or adverse
129-determination and notify the enrollee and the enrollee's health care provider of the decision
130-within seven calendar days of obtaining all necessary information to make the decision. For
131-purposes of this section, "necessary information" includes the results of any face-to-face
132-clinical evaluation or second opinion that may be required.
133-2.A prior authorization review organization shall have written procedures to address the failure
134-of a health care provider or enrollee to provide the necessary information to make a
135-determination on the request. If the health care provider or enrollee fails to provide the
136-necessary information to the prior authorization review organization within fourteen calendar
137-days of a written request for all necessary information, the prior authorization review
138-organization may make an adverse determination.
139-3.A prior authorization review organization shall allow an enrollee and the enrollee's health care
140-provider at least fourteen business days to request an updated prior authorization following an
141-unforeseen change in the circumstances or care needs for the enrollee following a nonurgent
142-circumstance or provision of health care services for the enrollee.
255+1.If a prior authorization review organization requires prior authorization of a health care
256+service, the prior authorization review organization shall make a prior authorization or
257+adverse determination and notify the enrollee and the enrollee's health care provider
258+of the decision within seven calendar days of obtaining all necessary information to
259+make the decision. For purposes of this section, "necessary information" includes the
260+results of any face-to-face clinical evaluation or second opinion that may be required.
261+2.A prior authorization review organization shall have written procedures to address the
262+failure of a health care provider or enrollee to provide the necessary information to
263+make a determination on the request. If the health care provider or enrollee fails to
264+provide the necessary information to the prior authorization review organization within
265+fourteen calendar days of a written request for all necessary information, the prior
266+authorization review organization may make an adverse determination.
267+3.A prior authorization review organization shall allow an enrollee and the enrollee's
268+health care provider at least fourteen business days to request an updated prior
269+authorization following an unforeseen change in the circumstances or care needs for
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303+the enrollee following a nonurgent circumstance or provision of health care services
304+for the enrollee .
143305 26.1 - 36.12 - 06. Prior authorization - Urgent health care services.
144-A prior authorization review organization shall render a prior authorization or adverse determination
145-concerning urgent health care services and notify the enrollee and the enrollee's health care provider of
146-that prior authorization or adverse determination within seventy - two hours after receiving all information
147-needed to complete the review of the requested health care services.
306+A prior authorization review organization shall render a prior authorization or adverse
307+determination concerning urgent health care services and notify the enrollee and the enrollee's
308+health care provider of that prior authorization or adverse determination within seventy - two
309+hours after receiving all information needed to complete the review of the requested health care
310+services.
148311 26.1 - 36.12 - 07. Prior authorization - Emergency medical condition.
149-1.A prior authorization review organization may not require prior authorization for prehospital
150-transportation or for the provision of emergency health care services for an emergency
151-medical condition.
152-2.A prior authorization review organization shall allow an enrollee and the enrollee's health care
153-provider a minimum of two business days following an emergency admission or provision of
154-emergency health care services for an emergency medical condition for the enrollee or health
155-care provider to notify the prior authorization review organization of the admission or provision
156-of health care services.
312+1.A prior authorization review organization may not require prior authorization for
313+prehospital transportation or for the provision of emergency health care services for an
314+emergency medical condition.
315+2.A prior authorization review organization shall allow an enrollee and the enrollee's
316+health care provider a minimum of two business days following an emergency
317+admission or provision of emergency health care services for an emergency medical
318+condition for the enrollee or health care provider to notify the prior authorization review
319+organization of the admission or provision of health care services.
157320 3.The medical necessity or appropriateness of emergency health care services for an
158-emergency medical condition may not be based on whether those services were provided by
159-participating or nonparticipating providers.
321+emergency medical condition may not be based on whether those services were
322+provided by participating or nonparticipating providers.
160323 4.If an enrollee receives an emergency health care service that requires immediate
161-postevaluation or poststabilization services, a prior authorization review organization shall
162-make an authorization determination within two business days of receiving a request. If the
163-authorization determination is not made within two business days, the services must be
164-deemed approved.
165-26.1 - 36.12 - 08. No prior authorization for medication-assisted treatment.
166-A prior authorization review organization may not require prior authorization for the provision of
167-medication-assisted treatment for the treatment of opioid use disorder. S. B. NO. 2280 - PAGE 5
324+postevaluation or poststabilization services, a prior authorization review organization
325+shall make an authorization determination within two business days of receiving a
326+request. If the authorization determination is not made within two business days, the
327+services must be deemed approved.
328+26.1 - 36.12 - 08. No prior authorization for medication assisted treatment.
329+A prior authorization review organization may not require prior authorization for the
330+provision of medication assisted treatment for the treatment of opioid use disorder.
168331 26.1 - 36.12 - 09. Retrospective denial.
169332 A prior authorization review organization may not revoke, limit, condition, or restrict a prior
170-authorization if care is provided within forty-five business days from the date the health care provider
171-received the prior authorization unless there is evidence the prior authorization was based on fraud.
333+authorization if care is provided within forty-five business days from the date the health care
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367+provider received the prior authorization unless there is evidence the prior authorization was
368+based on fraud.
172369 26.1 - 36.12 - 10. Length of prior authorization.
173-A prior authorization is valid for at least six months after the date the health care provider receives
174-the prior authorization.
370+A prior authorization is valid for at least six months after the date the health care provider
371+receives the prior authorization.
175372 26.1 - 36.12 - 11. Chronic or long-term care conditions.
176-If a prior authorization review organization requires a prior authorization for a health care service for
177-the treatment of a chronic or long-term care condition, the prior authorization remains valid for twelve
178-months.
373+If a prior authorization review organization requires a prior authorization for a health care
374+service for the treatment of a chronic or long-term care condition, the prior authorization
375+remains valid for twelve months.
179376 26.1 - 36.12 - 12. Continuity of care for enrollees.
180-1.On receipt of information documenting a prior authorization from the enrollee or from the
181-enrollee's health care provider, a prior authorization review organization shall honor a prior
182-authorization granted to an enrollee from a previous prior authorization review organization for
183-at least the initial sixty days of an enrollee's coverage under a new policy, provided the health
184-care service for which the enrollee has received prior authorization is covered under the new
185-policy. To obtain coverage, the enrollee or health care provider shall submit documentation of
186-the previous prior authorization in accordance with the procedures in the enrollee's new policy.
187-2.During the time period described in subsection 1, a prior authorization review organization
188-may perform its review to grant a prior authorization.
189-3.If there is a change in coverage of, or approval criteria for, a previously authorized health care
190-service, the change in coverage or approval criteria does not affect an enrollee who received
191-prior authorization before the effective date of the change for the remainder of the enrollee's
192-plan year. This subsection does not apply if a prior authorization review organization changes
377+1.On receipt of information documenting a prior authorization from the enrollee or from
378+the enrollee's health care provider, a prior authorization review organization shall
379+honor a prior authorization granted to an enrollee from a previous prior authorization
380+review organization for at least the initial sixty days of an enrollee's coverage under a
381+new policy, provided the health care service for which the enrollee has received prior
382+authorization is covered under the new policy. To obtain coverage, the enrollee or
383+health care provider shall submit documentation of the previous prior authorization in
384+accordance with the procedures in the enrollee's new policy.
385+2.During the time period described in subsection 1, a prior authorization review
386+organization may perform its review to grant a prior authorization.
387+3.If there is a change in coverage of, or approval criteria for, a previously authorized
388+health care service, the change in coverage or approval criteria does not affect an
389+enrollee who received prior authorization before the effective date of the change for
390+the remainder of the enrollee's plan year. This subsection does not apply if a prior
391+authorization review organization changes coverage terms for a drug or device that
392+has been:
393+a.Deemed unsafe by the United States food and drug administration; or
394+b.Withdrawn by the United States food and drug administration or product
395+manufacturer.
396+4.A prior authorization review organization shall continue to honor a prior authorization
397+the organization has granted to an enrollee if the enrollee changes products under the
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431+same health insurance company provided the health care service for which the
432+enrollee has received prior authorization is covered under the new policy.
433+26.1 - 36.12 - 13. Failure to comply - Services deemed authorized.
434+If a prior authorization review organization fails to comply with the deadlines and other
435+requirements in this chapter, any health care services subject to review automatically are
436+deemed authorized by the prior authorization review organization.
437+26.1 - 36.12 - 14. Procedures for appeals of adverse determinations.
438+1.A prior authorization review organization shall have written procedures for appeals of
439+adverse determinations. The right to appeal must be available to the enrollee and the
440+attending health care professional.
441+2.The enrollee may review the information relied on in the course of the appeal, present
442+evidence and testimony as part of the appeals process, and receive continued
443+coverage pending the outcome of the appeals process.
444+26.1 - 36.12 - 15. Effect of change in prior authorization clinical criteria.
445+1.If, during a plan year, a prior authorization review organization changes coverage
446+terms for a health care service or the clinical criteria used to conduct prior
447+authorizations for a health care service, the change in coverage terms or in clinical
448+criteria does not apply until the next plan year for any enrollee who received prior
449+authorization for a health care service using the coverage terms or clinical criteria in
450+effect before the effective date of the change.
451+2.This section does not apply if a prior authorization review organization changes
193452 coverage terms for a drug or device that has been:
194453 a.Deemed unsafe by the United States food and drug administration; or
195-b.Withdrawn by the United States food and drug administration or product manufacturer.
196-4.A prior authorization review organization shall continue to honor a prior authorization the
197-organization has granted to an enrollee if the enrollee changes products under the same
198-health insurance company provided the health care service for which the enrollee has
199-received prior authorization is covered under the new policy.
200-26.1 - 36.12 - 13. Failure to comply - Services deemed authorized.
201-If a prior authorization review organization fails to comply with the deadlines and other requirements
202-in this chapter, any health care services subject to review automatically are deemed authorized by the
203-prior authorization review organization.
204-26.1 - 36.12 - 14. Procedures for appeals of adverse determinations.
205-1.A prior authorization review organization shall have written procedures for appeals of adverse
206-determinations. The right to appeal must be available to the enrollee and the attending health
207-care professional. S. B. NO. 2280 - PAGE 6
208-2.The enrollee may review the information relied on in the course of the appeal, present
209-evidence and testimony as part of the appeals process, and receive continued coverage
210-pending the outcome of the appeals process.
211-26.1 - 36.12 - 15. Effect of change in prior authorization clinical criteria.
212-1.If, during a plan year, a prior authorization review organization changes coverage terms for a
213-health care service or the clinical criteria used to conduct prior authorizations for a health care
214-service, the change in coverage terms or in clinical criteria does not apply until the next plan
215-year for any enrollee who received prior authorization for a health care service using the
216-coverage terms or clinical criteria in effect before the effective date of the change.
217-2.This section does not apply if a prior authorization review organization changes coverage
218-terms for a drug or device that has been:
219-a.Deemed unsafe by the United States food and drug administration; or
220-b.Withdrawn by the United States food and drug administration or product manufacturer.
454+b.Withdrawn by the United States food and drug administration or product
455+manufacturer.
221456 26.1 - 36.12 - 16. Notification to claims administrator.
222-If the prior authorization review organization and the claims administrator are separate entities, the
223-prior authorization review organization shall notify, either electronically or in writing, the appropriate
224-claims administrator for the health benefit plan of any adverse determination that is reversed on appeal.
457+If the prior authorization review organization and the claims administrator are separate
458+entities, the prior authorization review organization shall notify, either electronically or in writing,
459+the appropriate claims administrator for the health benefit plan of any adverse determination
460+that is reversed on appeal.
225461 26.1 - 36.12 - 17. Annual report to insurance commissioner.
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226495 1.A prior authorization review organization shall report to the insurance commissioner by
227496 September first of each year information regarding prior authorization requests for the
228497 previous calendar year.
229498 2.The report must be available online and in a form specified by the commissioner.
230499 3.The report must include the:
231500 a.Total number of prior authorization requests received;
232501 b.Number of prior authorization requests for which an authorization was issued;
233-c.Number of prior authorization requests for which an adverse determination was issued;
502+c.Number of prior authorization requests for which an adverse determination was
503+issued;
234504 d.Number of adverse determinations reversed on appeal;
235505 e.Reasons an adverse determination was issued, expressed as a percentage of all
236506 adverse determinations, which must include:
237507 (1)The patient did not meet prior authorization criteria;
238-(2)Incomplete information was submitted by the provider to the prior authorization
239-review organization;
508+(2)Incomplete information was submitted by the provider to the prior
509+authorization review organization;
240510 (3)The treatment program changed; or
241511 (4)The patient is no longer covered by the health benefit plan;
242512 f.Number of prior authorization requests submitted but not necessary;
243-g.Number of prior authorization requests submitted by electronic means; and S. B. NO. 2280 - PAGE 7
244-h.Number of prior authorization requests submitted by nonelectronic means, including mail
245-and facsimile.
513+g.Number of prior authorization requests submitted by electronic means; and
514+h.Number of prior authorization requests submitted by nonelectronic means,
515+including mail and facsimile.
246516 SECTION 2. LEGISLATIVE MANAGEMENT STUDY - PRIOR AUTHORIZATION
247-REQUIREMENTS IMPOSED BY THE PUBLIC EMPLOYEES RETIREMENT SYSTEM UNIFORM
248-GROUP INSURANCE PROGRAM PLANS - INSURANCE COMMISSIONER DATA COLLECTION
249-AND REPORT TO LEGISLATIVE MANAGEMENT.
517+REQUIREMENTS IMPOSED BY THE PUBLIC EMPLOYEES RETIREMENT SYSTEM
518+UNIFORM GROUP INSURANCE PROGRAM PLANS - INSURANCE COMMISSIONER DATA
519+COLLECTION AND REPORT TO LEGISLATIVE MANAGEMENT.
250520 1.During the 2025-26 interim, the legislative management shall consider studying prior
251-authorization requirements imposed by the public employees retirement system uniform group
252-insurance plans under chapter 54-52.1 and the impact on patient care and health care costs.
253-2.The study must include input from stakeholders, including patients, providers, and commercial
254-insurance plans.
255-3.The study must require insurance plans to submit to the insurance commissioner by July 1,
256-2025, for the immediately preceding calendar year for each commercial product:
257-a.The number of prior authorization requests for which an authorization was issued;
258-b.The number of prior authorization requests for which an adverse determination was
259-issued, sorted by health care service, whether the adverse determination was appealed,
260-or whether the adverse determination was upheld or reversed on appeal;
521+authorization requirements imposed by the public employees retirement system
522+uniform group insurance plans under chapter 54-52.1 and the impact on patient care
523+and health care costs.
524+2.The study must include input from stakeholders, including patients, providers, and
525+commercial insurance plans.
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559+3.The study must require insurance plans to submit to the insurance commissioner by
560+July 1, 2025, for the immediately preceding calendar year for each commercial
561+product:
562+a.The number of prior authorization requests for which an authorization was
563+issued;
564+b.The number of prior authorization requests for which an adverse determination
565+was issued, sorted by health care service, whether the adverse determination
566+was appealed, or whether the adverse determination was upheld or reversed on
567+appeal;
261568 c.The reasons for prior authorization denial, including the patient did not meet prior
262569 authorization criteria, incomplete information was submitted by the provider to the
263-utilization review organization, a change in treatment program, or the patient is no longer
264-covered by the plan; and
570+utilization review organization, a change in treatment program, or the patient is
571+no longer covered by the plan; and
265572 d.The number of denials reversed by internal appeals or external reviews.
266573 4.The insurance commissioner shall aggregate this data into a report and submit it to the
267574 legislative management by November 1, 2025.
268-5.The legislative management shall report its findings and recommendations, together with any
269-legislation required to implement the recommendations, to the seventieth legislative assembly.
270-SECTION 3. LEGISLATIVE MANAGEMENT STUDY - PRIOR AUTHORIZATION ELECTRONIC
271-HEALTH RECORDS FOR NONURGENT AND EMERGENCY HEALTH CARE SERVICES. During the
272-2025-26 interim, the legislative management shall consider studying the ability for health care systems
273-and providers to submit prior authorization reviews for nonurgent and emergency health care services
274-by secure electronic means. The study must analyze alternatives to facsimile or mail for transmitting
275-prior authorization requests and the supporting medical records. The study must include input from
276-stakeholders, including patients, providers, and commercial insurance plans. The legislative
277-management shall report its findings and recommendations, together with any legislation required to
278-implement the recommendations, to the seventieth legislative assembly.
279-SECTION 4. EFFECTIVE DATE. This Act becomes effective on January 1, 2026. S. B. NO. 2280 - PAGE 8
280-____________________________ ____________________________
281-President of the Senate Speaker of the House
282-____________________________ ____________________________
283-Secretary of the Senate Chief Clerk of the House
284-This certifies that the within bill originated in the Senate of the Sixty-ninth Legislative Assembly of North
285-Dakota and is known on the records of that body as Senate Bill No. 2280.
286-Senate Vote:Yeas 43 Nays 3 Absent 1
287-House Vote: Yeas 93 Nays 0 Absent 1
288-____________________________
289-Secretary of the Senate
290-Received by the Governor at ________M. on _____________________________________, 2025.
291-Approved at ________M. on __________________________________________________, 2025.
292-____________________________
293-Governor
294-Filed in this office this ___________day of _______________________________________, 2025,
295-at ________ o’clock ________M.
296-____________________________
297-Secretary of State
575+5.The legislative management shall report its findings and recommendations, together
576+with any legislation required to implement the recommendations, to the seventieth
577+legislative assembly.
578+SECTION 3. LEGISLATIVE MANAGEMENT STUDY - PRIOR AUTHORIZATION
579+ELECTRONIC HEALTH RECORDS FOR NONURGENT AND EMERGENCY HEALTH CARE
580+SERVICES. During the 2025-26 interim, the legislative management shall consider studying the
581+ability for health care systems and providers to submit prior authorization reviews for nonurgent
582+and emergency health care services by secure electronic means. The study must analyze
583+alternatives to facsimile or mail for transmitting prior authorization requests and the supporting
584+medical records. The study must include input from stakeholders, including patients, providers,
585+and commercial insurance plans. The legislative management shall report its findings and
586+recommendations, together with any legislation required to implement the recommendations, to
587+the seventieth legislative assembly.
588+SECTION 4. EFFECTIVE DATE. This Act becomes effective on January 1, 2026.
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