Section 75-02-02-09.4 - General limitations on amount, duration, and scope1. Covered medical or remedial services or supplies are medically necessary when determined so by the medical provider unless the department has:a. Denied a prior treatment authorization request to provide the service;b. Imposed a limit that has been exceeded;c. Imposed a condition that has not been met;d. Upon review under North Dakota Century Code chapter 50-24.1, determined that the service or supplies are not medically necessary.2. Limitations on payment for occupational therapy, physical therapy, and speech therapy. a. No payment will be made for an occupational therapy evaluation except one per calendar year or for occupational therapy provided to individuals twenty-one years of age and older except for thirty visits per individual per calendar year unless the provider requests and receives prior authorization from the department. This limit applies in combination with services delivered by independent occupational therapists and in outpatient hospital settings.b. No payment will be made for a physical therapy evaluation except one per calendar year or for physical therapy provided to individuals twenty-one years of age and older except for thirty visits per individual per calendar year unless the provider requests and receives prior authorization from the department. This limit applies in combination with services delivered by independent physical therapists and in outpatient hospital settings.c. No payment will be made for a speech therapy evaluation except one per calendar year or for speech therapy provided to individuals twenty-one years of age and older except for thirty visits per individual per calendar year unless the provider requests and receives prior authorization from the department. This limit applies in combination with services delivered by independent speech therapists and in outpatient hospital settings.3. Limitation on payment for eye services. a. No payment will be made for eyeglasses for individuals twenty-one years of age and older except for one pair of eyeglasses no more often than once every two years. No payment will be made for the repair or replacement of eyeglasses during the two-year period unless the provider has secured the prior approval of the department and the department has found that the repair or replacement is medically necessary.b. No payment will be made for refractive examinations for individuals twenty-one years of age and older except for one refractive examination no more often than every two years after an initial examination paid by the department unless the provider has secured the prior approval of the department.4. Limitation on chiropractic services. a. No payment will be made for spinal manipulation treatment services except for twenty spinal manipulation treatment services per individual per calendar year unless the provider requests and receives the prior approval of the department.b. No payment will be made for radiologic examinations performed by a chiropractor except for two radiologic examinations per individual per year unless the provider requests and receives the prior approval of the department.N.D. Admin Code 75-02-02-09.4
Effective September 1, 2003; amended effective July 1, 2006; July 1, 2009; October 1, 2012.Amended by Administrative Rules Supplement 2016-360, April 2016, effective 4/1/2016.Amended by Administrative Rules Supplement 2017-363, January 2017, effective 1/1/2017.Amended by Administrative Rules Supplement 368, April 2018, effective 4/1/2018.Amended by Administrative Rules Supplement 2021-383, January 2022, effective 1/1/2022.General Authority: NDCC 50-24.1-04
Law Implemented: NDCC 50-24.1-04