Section 92-01-02-34 - Treatment requiring authorization, preservice review, and retrospective review1. Certain treatment procedures require prior authorization or preservice review by the organization or its managed care vendor. Requests for authorization or preservice review must include a statement of the condition diagnosed; their relationship to the compensable injury; the medical documentation supporting medical necessity, an outline of the proposed treatment program, its length and components, and expected prognosis.2. Requesting prior authorization or preservice review is the responsibility of the allied health care professional who provides or prescribes a service for which prior authorization or preservice review is required.3. Allied health care professionals shall request prior authorization directly from the claims adjuster for the items listed in this subsection. The claims adjuster shall respond to requests within fourteen days. a. Durable medical equipment. (1) The organization will pay rental fees for equipment if the need for the equipment is for a short period of treatment during the acute phase of a compensable work injury. The claims adjuster shall grant or deny authorization for reimbursement of equipment based on whether the claimant is eligible for coverage and whether the equipment prescribed is appropriate and medically necessary for treatment of the compensable injury. Rental extending beyond sixty days requires prior authorization from the claims adjuster. If the equipment is needed on a long-term basis, the organization may purchase the equipment. The claims adjuster shall base its decision to purchase the equipment on a comparison of the projected rental costs of the equipment to its purchase price. The organization shall purchase the equipment from the most cost-efficient source.(2) The claims adjuster will authorize and pay for durable medical equipment, including prosthetics and orthotics, as needed by the injured employee because of a compensable work injury when substantiated by the health care provider. If those items are furnished by the medical service provider or another provider, the organization will reimburse the medical service provider pursuant to its fee schedule. Medical service providers shall supply the organization with a copy of their original invoice showing actual cost of the item upon request of the organization. Actual cost is a factor considered in determining cost-effectiveness under North Dakota Century Code section 65-02-20. The organization will repair or replace originally provided damaged, broken, or worn-out prosthetics, orthotics, or special equipment devices upon documentation from the health care provider that replacement or repair is needed. Prior authorization for replacements is required.(3) Equipment costing less than five hundred dollars does not require prior authorization, but remains subject to the organization's durable medical equipment guidelines. (4) An injured employee must obtain a health care provider's order of medical necessity before the purchase of a mobility assistance device.(5) The organization may require assessments to determine the functional levels of an injured worker who is being considered for a mobility assistance device.b. Biofeedback programs; pain clinics; psychotherapy; physical rehabilitation programs, including health club memberships and work hardening programs; chronic pain management programs; and other programs designed to treat special problems.c. Concurrent care. In some cases, treatment by more than one medical service provider may be allowed. The claims adjuster will consider concurrent treatment when the accepted conditions resulting from the injury involve more than one system or require specialty or multidisciplinary care. When requesting consideration for concurrent treatment, the primary health care provider must provide the claims adjuster with the name, address, discipline, and specialty of all other medical service providers assisting in the treatment of the injured employee and with an outline of their responsibility in the case and an estimate of how long concurrent care is needed. When concurrent treatment is allowed, the organization will recognize one primary health care provider, who is responsible for prescribing all medications if the primary health care provider is authorized to prescribe medications; directing the overall treatment program; providing copies of all reports and other data received from the involved medical service providers; and, in time loss cases, providing adequate certification evidence of the injured employee's ability to perform work. The claims adjuster will approve concurrent care on a case-by-case basis. Except for emergency services, all treatments must be authorized by the injured employee's primary health care provider to be reimbursable.d. Telehealth. The organization may pay for audio and video telecommunications instead of a face-to-face "hands on" appointment for CPT codes designated by the American medical association as teleheath codes. As a condition of payment, the patient must be present and participating in the telemedicine appointment. The professional fee payable is equal to the fee schedule amount for the service provided. The organization may pay the originating site a facility fee at the scheduled amount.4. Notwithstanding the requirements of subsection 5, the organization may designate certain exemptions from preservice review requirements in conjunction with programs designed to ensure the ongoing evolution of managed care to meet the needs of injured workers and providers.5. Medical service providers shall request preservice review from the utilization review department for:a. All nonemergent inpatient hospital admissions or nonemergent inpatient surgery and outpatient surgical procedures.b. All nonemergent major surgery. When the primary health care provider or consulting health care provider believes elective surgery is needed to treat a compensable injury, the primary health care provider or the consulting health care provider with the approval of the primary health care provider, shall give the utilization review department actual notice at least seventy-two hours prior to the proposed surgery. Notice must give the medical information that substantiates the need for surgery, an estimate of the surgical date and the postsurgical recovery period, and the hospital where surgery is to be performed. When elective surgery is recommended, the utilization review department may require an independent consultation with a health care provider of the organization's choice. The organization shall notify the health care provider who requested approval of the elective surgery, whether or not a consultation is desired. When requested, the consultation must be completed within thirty days after notice to the primary health care provider. Within seven days of the consultation, the organization shall notify the surgeon of the consultant's findings. If the primary health care provider and consultant disagree about the need for surgery, the organization may request a third independent opinion pursuant to North Dakota Century Code section 65-05-28. If, after reviewing the third opinion, the organization believes the proposed surgery is excessive, inappropriate, or ineffective and the organization cannot resolve the dispute with the primary health care provider, the requesting health care provider may request binding dispute resolution in accordance with section 92-01-02-46. c. Magnetic resonance imaging, a myelogram, discogram, bonescan, arthrogram, or computed axial tomography. Tomograms are subject to preservice review if requested in conjunction with a myelogram, discogram, bonescan, arthrogram, computed axial tomography scan, or magnetic resonance imaging. Computed axial tomography completed within thirty days from the date of injury may be performed without prior authorization. The organization may waive preservice review requirements for procedures listed in this subdivision when requested by a health care provider who is performing an independent medical examination or permanent partial impairment evaluation at the request of the organization.d. Physical therapy and occupational therapy treatment beyond the first ten treatments or beyond sixty days after first prescribed, whichever occurs first, or physical therapy and occupational therapy treatment after an inpatient surgery, outpatient surgery, or ambulatory surgery beyond the first ten treatments or beyond sixty days after therapy services are originally prescribed, whichever occurs first. Postoperative physical therapy and occupational therapy may not be started beyond ninety days after surgery date. The organization may waive this requirement in conjunction with programs designed to ensure the ongoing evolution of managed care to meet the needs of injured claimants or providers. Modalities for outpatient physical therapy services and outpatient occupational therapy services are limited to two per visit during the sixty-day or ten-treatment ranges set out in this subsection. The number of units performed and billed per visit may not exceed four unless otherwise approved.e. All nonemergent air ambulance services. When the primary health care provider or consulting health care provider believes transfer to another treatment facility is needed to treat a compensable injury, the primary health care provider or the consulting health care provider or the transferring treatment facility, with the approval of the primary health care provider, shall give the utilization review department actual notice prior to the proposed transfer to the receiving treatment facility. Notice must give the medical information that substantiates the need for transfer via air ambulance service, the name of the treatment facility where transfer will occur, air service provider, and estimated cost. The organization will review the cost effectiveness and alternatives and provide notice to the requesting health care provider or treatment facility within twenty-four hours, or by the end of the next business day.g. Intra-articular injection of hyaluronic acid.h. Facet joint injections. i. Sacroiliac joint injections.k. Epidural steroid injections.m. Peripheral nerve blocks.o. Stellate ganglion blocks.q. Radio frequency lesioning.s. Implantation of stimulators and pumps.u. The organization will review all opioid therapies for medical necessity following the conclusion of a chronic opioid therapy. For injured employees whose chronic opioid therapies have been discontinued for noncompliance with North Dakota Century Code section 65-05-39, any subsequent opioid therapies may not exceed ninety days.6. Chiropractic providers shall request preservice review from the organization's chiropractic managed care vendor for chiropractic treatment beyond the first ten treatments or beyond sixty days after the first treatment, whichever occurs first. The evaluation to determine a treatment plan is not subject to review. The organization may waive this subsection in conjunction with programs designed to ensure the ongoing evolution of managed care to meet the needs of injured employees or providers. Modalities for chiropractic services are limited to two per visit during the sixty-day or ten-treatment ranges set out in this subsection.7. The organization may designate those diagnostic and surgical procedures that can be performed in other than a hospital inpatient setting.8. The organization or managed care vendor must respond to the medical service provider within three business days of receiving the necessary information to complete a review and make a recommendation on the service. Within the time for review, the organization or managed care vendor must recommend approval or denial of the request, request additional information, request the injured employee obtain a second opinion, or request an examination by the injured employee's health care provider. A recommendation to deny medical services must specify the reason for the denial.9. The organization may conduct retrospective reviews of medical services and subsequently reimburse medical service providers only:a. If preservice review or prior authorization of a medical service is requested by a medical service provider and an injured employee's claim status in the adjudication process is pending or closed; orb. If preservice review or prior authorization of a medical service is not requested by a medical service provider and the medical service provider can prove, by a preponderance of the evidence, that the injured employee did not inform the medical service provider, and the medical service provider did not know, that the condition was, or likely would be, covered under workers' compensation. All medical service providers are required to cooperate with the managed care vendor for retrospective review and are required to provide, without additional charge to the organization or the managed care vendor, the medical information requested in relation to the reviewed service.
10. The organization must notify medical service provider associations of the review requirements of this section prior to the effective date of these rules.11. The organization must respond to the medical service provider within thirty days of receiving a retrospective review request.N.D. Admin Code 92-01-02-34
Amended by Administrative Rules Supplement 2014-352, April 2014, effective April 1, 2014. .Amended by Administrative Rules Supplement 2016-360, April 2016, effective 4/1/2016.Amended by Administrative Rules Supplement 2017-365, July 2017, effective 7/1/2017.Amended by Administrative Rules Supplement 376, April 2020, effective 4/1/2020.General Authority: NDCC 65-02-08, 65-02-20, 65-05-07
Law Implemented: NDCC 65-02-20, 65-05-07