Utilization Review Licensing in North Dakota

Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in North Dakota. For assistance with licensing, please contact us to learn about our software and managed license services.

North Dakota Utilization Review Agent Certification

Type of Review:

Medical Utilization Review

Agency:North Dakota Insurance Department
Law:

NDCC § 26.1-26.4

Initial Registration

Form:

Utilization Review Agent Certification and Utilization Review Filing Report

Agency Fee:

$0

Notarize:Required
Required Attachments:
  • A description of the appeal procedures for utilization review determinations
  • A list of the third-party payers for whom the private review agent is performing utilization review in the state
  • Copy of URAC or NCQA Accreditation - specifying the program (if applicable)
  • The name of the physician, practitioner or psychologist that will be conducting the utilization reviews (North Dakota board certified)

Registration Renewal

Form:

Utilization Review Agent Certification (Renewal)

Agency Fee:

$0

Due:

Annually by March 1.

Notarize:Required

North Dakota Resources

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Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

Revised February 22, 2021. Complete data last reviewed February 22, 2021.
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