Chapter 01-02. Rules of Procedure - North Dakota Workers' Compensation Act

1. Medical services. a. Medical services that are not medically necessary are not reimbursable. b. Frequency and extent of treatment may not be more than the nature of the injury or process of recovery requires, and must be provided in accordance with utilization and treatment st…

1. Treatment that falls within the scope and field of the treating allied health care professional's license to practice is reimbursable. 2. Paraprofessionals who are not independently licensed shall practice under the direct supervision of a licensed allied health care professio…

Physician assistants may be reimbursed within the scope of their licenses for services performed under the supervision of a licensed physician. History: Effective January 1, 1994; amended effective October 1, 1998; January 1, 2000; May 1, 2002; April 1, 2009; April 1, 2020. Gener…

certified athletic trainers. Physical therapist assistants, certified occupational therapist assistants, and certified athletic trainers may be reimbursed when providing treatment under the direction and general supervision of the physical therapist or occupational therapist. Phy…

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. P…

review. 1. Certain treatment procedures require prior authorization or preservice review by the organization or its managed care vendor. Requests for prior authorization or preservice review must include a statement of the condition diagnosed; their relationship to the compensabl…

Repealed effective October 1, 1998.

Repealed effective October 1, 1998.

Repealed effective October 1, 1998.

1. All changes from one health care provider to another must be approved by the organization. Normally, changes will be allowed only after the injured employee has been under the care of the primary health care provider for sufficient time for the health care provider to complete…

Repealed effective October 1, 1998.

Repealed effective January 1, 2022.

1. The organization may request an independent medical examination or independent medical review pursuant to North Dakota Century Code section 65-05-28. 2. The organization shall provide at least fourteen days' notice to the injured employee of an independent medical examination.…

Repealed effective October 1, 1998.

1. When the primary health care provider believes special or attendant (home nurse) care is needed, the health care provider shall submit the following information: a. A description of the special or home nursing care required, including the estimated time required (i.e., cathete…

The organization may enter into special agreements for services provided by, or under the direction of, licensed medical service providers authorized to bill the organization. Special agreements may be made for services not covered under the fee schedule and may include multidisc…

1. As soon as reasonably possible after receiving a bill, the organization shall: a. Pay the charge or any portion of the bill that is not denied; b. Deny all or a portion of the bill on the basis that the injury is not compensable, or the service or charge is excessive or not me…

1. A medical service provider shall complete the registration process and corresponding forms identified by the organization to receive payments for services. 2. A medical service provider may not submit a charge for a service which exceeds the amount the medical service provider…

Medical service providers shall submit electronic medical bills and supporting documentation to the organization unless the health care provider is exempt. 1. A medical service provider is exempt from the requirement of electronic submission of medical bills if: a. The provider s…

1. This rule provides the procedures followed for managed care disputes. Retrospective review is the procedure provided for disputing the denial of payment for a medical service charge based on failure to request prior authorization or preservice review. Binding dispute resolutio…

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 Cent…

Repealed effective March 1, 2000. 47

1. For purposes of this section, unless the context otherwise requires: a. "Appropriate record" means a legible medical record or report from a provider, or any other relevant and material information, substantiating the type, nature, extent, and work-relatedness of an injury, wh…

1. Any service performed for another for remuneration under any agreement or contract of hire express or implied is presumed to be employment unless it is shown that the individual performing the service is an independent contractor as determined by the "common law" test. a. An e…

A person may apply to the organization for a determination of whether that person is an employer as that term is defined by North Dakota Century Code title 65. A person claiming not to be an employer under the Workers' Compensation Act has the burden of proving by a preponderance…

1. The organization may reimburse attorney fees and costs under this section regardless of the state in which the injury occurred. 2. The organization retains the ability to select or approve counsel secured by the employer. 3. Employers shall submit attorney billing statements f…

1. The terms used in this section have the same meaning as in North Dakota Century Code title 65 and in North Dakota Administrative Code title 92, except: a. "Covered employment" means hazardous employment principally localized in this state which involves incidental operations i…

Repealed effective July 1, 2006.

Any person, as defined in North Dakota Century Code section 1-01-49, served with a subpoena by the organization which directs the production of copies of documents may charge the organization copying costs. Those persons shall charge, and the organization shall pay, no more than …

As used in subsection 3 of North Dakota Century Code section 65-05-08 and North Dakota Century Code section 65-05-33, "work" means physical or mental effort exerted to do or to make something for any amount of remuneration or physical or mental effort exerted to do or to make som…

Repealed effective May 1, 2002.

Refund. An applicant for a workers' compensation scholarship offered under North Dakota Century Code section 65-05-20.1 must complete the application form required by the organization. The form, at a minimum, must require the applicant provide: 1. Name, address, date of birth, se…

The organization may award grants to entities to promote injured workers' skill upgrading, remedial education, and optimal transition into the labor force. To be eligible, entities must submit proposals that identify a vocational need and explain how the entity intends to meet it…

The organization and an employer may contract for a deductible program. When a deductible program contract is entered, the employer shall reimburse the organization for benefits payable on individual claims up to the agreed deductible amount. The organization shall provide a redu…

The organization may offer dividends to qualifying employers. Eligibility and distribution: 1. Dividends are not guaranteed. 2. If an employer's account has been in effect for less than an entire premium year, any dividend offered shall be prorated by the number of months the emp…

Repealed effective January 1, 2024.

An employer may file an incident report with the organization through the organization's web site. If an incident report is filed with the organization by midnight central time of the next organization business day following the workplace injury or incident and a claim is filed f…

1. Applicants for this premium credit shall complete and submit a complete application provided by the organization. The organization may decline an application for this program. 2. An applicant must be in good standing, as defined in section 92-05-02-01(2), with the organization…