Title 26.1 — Insurance

This chapter applies to grandfathered health plans unless a health care insurer or utilization review agent determines to extend the protections of section 26.1-36-47 to a grandfathered plan. "Grandfathered health plan" has the meaning stated in the Patient Protection and Afforda…

For purposes of this chapter, unless the context requires otherwise: 1. "Commissioner" means the insurance commissioner. 2. "Emergency medical condition" means a medical condition of recent onset and severity, including severe pain, that would lead a prudent layperson acting reas…

A utilization review agent may not conduct utilization review in this state unless the utilization review agent has certified to the commissioner in writing that the agent is in compliance with section 26.1-26.4-04. Certification must be made annually on or before March first of …

All utilization review agents must meet the following minimum standards: 1. Notification of a determination by the utilization review agent must be provided to the enrollee or other appropriate individual in accordance with 29 U.S.C. 1133 and the timeframes set forth in 29 CFR 25…

A utilization review agent is deemed to be conducting utilization review in this state if the agent conducts utilization review involving services rendered or to be rendered in the state regardless of where the agent actually performs the utilization review. No person may be empl…

A health care insurer that contracts with another entity to perform utilization review on its behalf remains responsible to ensure that all the requirements of this chapter are met to the same extent the health care insurer would be if it performed the utilization review itself.

Whenever the commissioner has reason to believe that a utilization review agent subject to this chapter has been or is engaged in conduct that violates section 26.1-26.4-03 or 26.1-26.4-04, the commissioner shall notify the utilization review agent of the alleged violation. The u…