Section 92-01-02-46.1 - Pharmacy services disputes1. 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.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.N.D. Admin Code 92-01-02-46.1
Adopted by Administrative Rules Supplement 376, April 2020, effective 4/1/2020.General Authority: NDCC 65-02-08
Law Implemented: NDCC 65-02-20