26.1-36.12-04. Personnel qualified to review appeals

26.1-36.12-04. Personnel qualified to review appeals

1. A prior authorization review organization shall ensure all appeals are reviewed by a

physician. The reviewing individual:

a. Shall possess a valid nonrestricted license to practice medicine.

b. Must be in active practice in the same or similar specialty as the physician who

typically manages the medical condition or disease for at least five consecutive

years.

c. Must be knowledgeable of, and have experience providing, the health care

services under appeal.

d. May not receive any financial incentive based on the number of adverse

determinations made. This subdivision does not apply to financial incentives

established between health plan companies and health care providers.

e. May not have been directly involved in making the adverse determination.

f. Shall consider all known clinical aspects of the health care service under review,

including a review of all pertinent medical records provided to the prior

authorization review organization by the enrollee's health care provider, any

relevant records provided to the prior authorization review organization by a

health care facility, and any medical literature provided to the prior authorization

review organization by the health care provider.

2. A review of an adverse determination involving a prescription drug must be conducted

by a licensed pharmacist or physician who is competent to evaluate the specific

clinical issues presented in the review.

3. This section does not apply to reviews conducted under sections 26.1-36-44 and

26.1-36-46.