26.1-36.12-03. Personnel qualified to make adverse determinations

26.1-36.12-03. Personnel qualified to make adverse determinations A prior authorization review organization shall ensure all adverse determinations are made by a licensed physician or licensed pharmacist. The reviewing individual: 1. Must have experience treating patients with the condition or illness for which the health care service is being requested; and 2. Shall make the adverse determination under the clinical direction of one of the prior authorization review organization's medical directors who is responsible for the health care services provided to enrollees.