# N.D. Cent. Code § 26.1-36.12-01: 26.1-36.12-01. Definitions > North Dakota · Statutes · In force URL: https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-01 ## Section - **Citation:** N.D. Cent. Code § 26.1-36.12-01 - **Heading:** 26.1-36.12-01. Definitions - **Jurisdiction:** North Dakota - **Kind:** Statutes - **Status:** In force - **Text as of:** August 14, 2026 - **Source:** Compiled text - **Location:** ND Code / Title 26.1 / Chapter 26.1-36.12 / Section 26.1-36.12-01 ## Text 26.1-36.12-01. Definitions As used in this chapter: 1. "Adverse determination" means a decision by a prior authorization review organization relating to an admission, extension of stay, or health care service that is partially or wholly adverse to the enrollee, including a decision to deny an admission, extension of stay, or health care service on the basis it is not medically necessary. 2. "Appeal" means a formal request, either orally or in writing, to reconsider an adverse determination regarding an admission, extension of stay, or health care service. 3. "Authorization" means a determination by a prior authorization review organization that a health care service has been reviewed and, based on the information provided, satisfies the prior authorization review organization's requirements for medical necessity and appropriateness, and payment will be made for that health care service. 4. "Clinical criteria" means the written policies, written screening procedures, drug formularies or lists of covered drugs, determination rules, determination abstracts, clinical protocols, practice guidelines, medical protocols, and any other criteria or rationale used by the prior authorization review organization to determine the necessity and appropriateness of health care services. 5. "Emergency health care services" means health care services, supplies, or treatments furnished or required to screen, evaluate, and treat an emergency medical condition. 6. "Emergency medical condition" means a medical condition that manifests itself by symptoms of sufficient severity which may include pain and that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of medical attention to result in placing the individual's health in jeopardy, impairment of a bodily function, or dysfunction of any body part. 7. "Enrollee" means an individual who has contracted for or who participates in coverage under a policy for that individual or that individual's eligible dependents. 8. "Health care services" means health care procedures, treatments, or services provided by a licensed facility or provided by a licensed physician or within the scope of practice for which a health care professional is licensed. The term includes the provision of pharmaceutical products or services or durable medical equipment. 9. "Medically necessary" as the term applies to health care services means health care services a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is: a. In accordance with generally accepted standards of medical practice; b. Clinically appropriate in terms of type, frequency, extent, site, and duration; and c. Not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other health care provider. 10. "Medication-assisted treatment" means the use of medications, commonly in combination with counseling and behavioral therapies, to provide a comprehensive approach to the treatment of substance use disorders. United States food and drug administration-approved medications used to treat opioid addiction include methadone and buprenorphine, alone or in combination with naloxone and extended-release injectable naltrexone. Types of behavioral therapies include individual therapy, group counseling, family behavior therapy, motivational incentives, and other modalities. 11. "Policy" means a health benefit plan as defined in section 26.1-36.3-01. The term does not include medical assistance or the public employees retirement system uniform group insurance program plans under chapter 54-52.1. 12. "Prior authorization" means the review conducted before the delivery of a health care service, including an outpatient health care service, to evaluate the necessity, 11. "Policy" means a health benefit plan as defined in section 26.1-36.3-01. The term does not include medical assistance or the public employees retirement system uniform group insurance program plans under chapter 54-52.1. 12. "Prior authorization" means the review conducted before the delivery of a health care service, including an outpatient health care service, to evaluate the necessity, appropriateness, and efficacy of the use of health care services, procedures, and facilities, by a person other than the attending health care professional, for the purpose of determining the medical necessity of the health care services or admission. The term includes a review conducted after the admission of the enrollee and in situations in which the enrollee is unconscious or otherwise unable to provide advance notification. The term does not include a referral or participation in a referral process by a participating provider unless the provider is acting as a prior authorization review organization. 13. "Prior authorization review organization" means a person that performs prior authorization for: a. An employer with employees in the state who are covered under a policy; b. An insurer that writes policies; c. A preferred provider organization or health maintenance organization; or d. Any other person that provides, offers to provide, or administers hospital, outpatient, medical, prescription drug, or other health benefits to an individual treated by a health care professional in the state under a policy. 14. "Urgent health care service" means a health care service for which, in the opinion of a health care professional with knowledge of the enrollee's medical condition, the application of the time periods for making a nonexpedited prior authorization might: a. Jeopardize the life or health of the enrollee or the ability of the enrollee to regain maximum function; or b. Subject the enrollee to pain that cannot be managed adequately without the care or treatment that is the subject of the prior authorization review. ## Nearby sections - [N.D. Cent. Code § 26.1-36.12-01 26.1-36.12-01. Definitions](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-01.md) - [N.D. Cent. Code § 26.1-36.12-02 26.1-36.12-02. Disclosure and review of prior authorization requirements](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-02.md) - [N.D. Cent. Code § 26.1-36.12-03 26.1-36.12-03. Personnel qualified to make adverse determinations](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-03.md) - [N.D. Cent. Code § 26.1-36.12-04 26.1-36.12-04. Personnel qualified to review appeals](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-04.md) - [N.D. Cent. Code § 26.1-36.12-05 26.1-36.12-05. Prior authorization - Nonurgent circumstances](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-05.md) - [N.D. Cent. Code § 26.1-36.12-06 26.1-36.12-06. Prior authorization - Urgent health care services](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-06.md) - [N.D. Cent. Code § 26.1-36.12-07 26.1-36.12-07. Prior authorization - Emergency medical condition](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-07.md) - [N.D. Cent. Code § 26.1-36.12-08 26.1-36.12-08. No prior authorization for medication-assisted treatment](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-08.md) - [N.D. Cent. Code § 26.1-36.12-09 26.1-36.12-09. Retrospective denial](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-09.md) - [N.D. Cent. Code § 26.1-36.12-10 26.1-36.12-10. Length of prior authorization](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-10.md) - [N.D. Cent. Code § 26.1-36.12-11 26.1-36.12-11. Chronic or long-term care conditions](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-11.md) - [N.D. Cent. Code § 26.1-36.12-12 26.1-36.12-12. Continuity of care for enrollees](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-12.md) - [N.D. Cent. Code § 26.1-36.12-13 26.1-36.12-13. Failure to comply - Services deemed authorized](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-13.md) - [N.D. Cent. Code § 26.1-36.12-14 26.1-36.12-14. Procedures for appeals of adverse determinations](https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-14.md) --- Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_ND_T26.1_C26.1-36.12_S26.1-36.12-01. Check the current official text before relying on it. Not legal advice.