Medical services disputes

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 resolution is the procedure provided for disputing managed care recommendations, including bill audit and review. Disputes not arising from managed care follow the reconsideration and hearing procedures provided by North Dakota Century Code section 65-01-16. 2. If the organization denies payment for a medical service charge because the medical service provider did not properly request prior authorization or preservice review for that service, the medical service provider may request a retrospective review of that service. Requests for retrospective review must be made in writing, within thirty days after the notice that payment for the service is denied, addressed to the organization utilization review department. Requests for retrospective review should 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. d. A statement of why the medical service provider did not know and should not have known that the injury or condition may be a compensable injury. e. The information required to perform a preservice review or prior authorization of the service. If the medical service provider knew or should have known that the patient may have a compensable work injury when the medical services for that injury were provided, the request for retrospective review must be denied. If the medical service provider did not know and should not have known that the patient may have a compensable work injury when the medical services for that injury were provided, a retrospective preservice review or prior authorization may be done. The organization may determine if the medical review is required to determine medical necessity, or if the medical review is waived based on the supporting documentation. If the organization continues to deny payment for the service, the medical service provider may request binding dispute resolution under this rule. 3. A party who wishes to dispute a utilization review recommendation first shall exhaust any internal dispute resolution procedures provided by the managed care vendor or the utilization review department. A party who wishes to dispute a final recommendation of a managed care vendor or a prior authorization or preservice review decision under section 92-01-02-34 shall file a written request for binding dispute resolution with the organization within thirty days after the final recommendation or decision. The request must contain: a. The injured employee's name. b. The claim number. c. All relevant medical information and documentation. d. A statement of any actual or potential harm to the injured employee from the recommendation. e. The specific relief sought. 4. A party who wishes to dispute a denial or reduction of a service charge arising from bill audit and review shall file a written request for binding dispute resolution with the organization within thirty days after the date of the organization's remittance advice reducing or denying the charge. The request must contain: a. The injured employee's name. b. The claim number. c. The specific code and the date of the service in dispute. d. A statement of the reasons the reduction or denial was incorrect, with any supporting documentation. e. The specific relief sought. 5. 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. 6. The organization may request review by allied health care professionals, at least one of whom must be licensed or certified in the same profession as the allied health care professional whose treatment is being reviewed, or by an external expert in medical coding or other aspects of medical treatment or billing, to assist with its review of the request. The organization may request an independent medical examination to assist with its review of a request. 7. 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.