N.D. Admin Code 92-01-02-33 - Utilization review and quality assurance
The organization has instituted a program of utilization review and quality assurance to monitor and control the use of health care services. The organization shall develop and identify the mode and manner of submissions for utilization review and quality assurance requests.
1. Prior authorization for services must be
obtained from the organization or its managed care vendor at least seventy-two
hours or three business days in advance of providing certain medical treatment,
equipment, or supplies. Medical services requiring prior authorization or
preservice review are outlined in section 92-01-02-34. Emergency medical
services may be provided without prior authorization, but notification is
required within twenty-four hours of, or by the end of the next business day
following, initiation of emergency treatment. Reimbursement may be withheld, or
recovery of prior payments made, if utilization review does not confirm the
medical necessity of emergency medical services.
2. Documentation of the need for and efficacy
of continued medical care by the allied health care professional is required at
the direction or request of the organization or the managed care vendor while a
claim is open.
3. The organization
may require second opinion consultations prior to the authorization of
reimbursement for surgery and for conservative care which extends past sixty
days following the initial visit.
4. The organization may require preoperative
psychosocial screens and psychological evaluations prior to the authorization
of reimbursement for surgery. The organization may select the evaluators who
will perform the screens and evaluations.
5. The organization may use the Official
Disability Guidelines, the American College of Occupational and Environmental
Medicine's Occupational Medicine Practice Guidelines, Guide to Physical Therapy
Practice, The Medical Disability Advisor, Diagnosis and Treatment for
Physicians and Therapists Upper Extremity Rehabilitation, Treatment Guidelines
of the American Society of Hand Therapists, American Medical Association Guides
to the Evaluation of Disease and Injury Causation, or any other treatment and
disability guidelines or standards it deems appropriate to administer claims.
Notes
General Authority: NDCC 65-02-08, 65-02-20, 65-05-07
Law Implemented: NDCC 65-02-20, 65-05-07
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