N.D. Admin Code 92-01-02-46.1 - Pharmacy services disputes
1. Binding
dispute resolution must be used for disputing managed care recommendations,
including point of sale alterations or denials for pharmacy services. Disputes
not arising from managed care must follow the reconsideration and hearing
procedures provided by North Dakota Century Code section 65-01-16.
2. When the organization denies payment for a
pharmacy service charge the medical service provider or injured employee may
request review of that service. Requests for review must be made in writing,
within thirty days after the initial denial of payment, addressed to the
organization claims adjuster assigned to handle the injured employee's claim.
Requests for review may not be sent to the managed care vendor. The request
must contain:
a. The injured employee's
name.
b. The claim
number.
c. The date of service and
service denied.
d. The specific
relief sought.
e. The information
required to perform a review of the service. If the organization continues to
deny payment for the service, the medical service provider may request binding
dispute resolution under this rule.
3. The organization shall review the request
for binding dispute resolution and the relevant information in the record. The
organization may request additional information or documentation. If a party
does not provide the requested information within fourteen days, the
organization may decide the dispute on the information in the record.
4. At the conclusion of its review, the
organization shall issue its binding decision. The organization shall issue its
decision by letter or notice, or for a decision that is reviewable by law, the
organization may issue its decision in an administrative order instead of a
letter or notice.
Notes
General Authority: NDCC 65-02-08
Law Implemented: NDCC 65-02-20
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