N.D. Admin. Code 92-01-02-45

Current through Supplement No. 394, October, 2024

Section 92-01-02-45 - Organization responsibilities

1. As soon as reasonably possible after receiving a bill, the organization shall:

a. Pay the charge or any portion of the bill that is not denied;

b. Deny all or a portion of the bill on the basis that the injury is not compensable, or the service or charge is excessive or not medically necessary; or

c. Request specific additional information to determine whether the charge or service is excessive or not medically necessary or whether the condition is compensable.

2. The organization shall provide notice of nonpayment to the injured employee when the injured employee is personally responsible for the payment of a charge. The organization shall provide notice of nonpayment to the medical service provider through a remittance advice of denial of part or all of a charge, or shall provide notice to the medical service provider for any request for additional information. The notice must include:

a. The basis for denying all or part of a charge because the treatment was not for a compensable injury.

b. The basis for denying or reducing excessive charges and the specific amounts denied or reduced.

c. The basis for denying the charge for an excessive service.

d. The basis for denying a charge as not being medically necessary.

e. A request for records or other information needed to allow proper determination of the bill.

3. Any payment incorrectly made to a medical service provider may be recovered from the medical service provider by the organization.

4. The organization will pay a reasonable fee for a special report as defined in section 92-01-02-29 prepared at the request of the organization. The allied health care professional shall include in the special report the time required to prepare the report or the organization may not pay for the report. Time spent and the complexity of the issues will be considered when determining the reasonableness of the fee. Such services should be billed under current procedural terminology code 99080 with a description of "special report".

N.D. Admin Code 92-01-02-45

Effective January 1, 1994; amended effective April 1, 1997; October 1, 1998.

Amended by Administrative Rules Supplement 376, April 2020, effective 4/1/2020.

General Authority: NDCC 65-02-08, 65-02-20, 65-05-07

Law Implemented: NDCC 65-02-20, 65-05-07