North Dakota Administrative Code › Title 92 - Workforce Safety and Insurance › Article 92-01 - General Administration › Chapter 92-01-02 - Rules of Procedure - North Dakota Workers' Compensation Act › Section 92-01-02-34 - Treatment requiring authorization, preservice review, and retrospective review

Current through Supplement No. 393, July, 2024
1. Certain
				treatment procedures require prior authorization or preservice review by the
				organization or its managed care vendor. Requests for authorization or
				preservice review must include a statement of the condition diagnosed; their
				relationship to the compensable injury; the medical documentation supporting
				medical necessity, an outline of the proposed treatment program, its length and
				components, and expected prognosis.
2. Requesting prior authorization or
				preservice review is the responsibility of the allied health care professional
				who provides or prescribes a service for which prior authorization or
				preservice review is required.
3.
				Allied health care professionals shall request prior authorization directly
				from the claims adjuster for the items listed in this subsection. The claims
				adjuster shall respond to requests within fourteen days.
a. Durable medical equipment.
(1) The organization will pay rental fees for
				equipment if the need for the equipment is for a short period of treatment
				during the acute phase of a compensable work injury. The claims adjuster shall
				grant or deny authorization for reimbursement of equipment based on whether the
				claimant is eligible for coverage and whether the equipment prescribed is
				appropriate and medically necessary for treatment of the compensable injury.
				Rental extending beyond sixty days requires prior authorization from the claims
				adjuster. If the equipment is needed on a long-term basis, the organization may
				purchase the equipment. The claims adjuster shall base its decision to purchase
				the equipment on a comparison of the projected rental costs of the equipment to
				its purchase price. The organization shall purchase the equipment from the most
				cost-efficient source.
(2) The
				claims adjuster will authorize and pay for durable medical equipment, including
				prosthetics and orthotics, as needed by the injured employee because of a
				compensable work injury when substantiated by the health care provider. If
				those items are furnished by the medical service provider or another provider,
				the organization will reimburse the medical service provider pursuant to its
				fee schedule. Medical service providers shall supply the organization with a
				copy of their original invoice showing actual cost of the item upon request of
				the organization. Actual cost is a factor considered in determining
				cost-effectiveness under North Dakota Century Code section 65-02-20. The
				organization will repair or replace originally provided damaged, broken, or
				worn-out prosthetics, orthotics, or special equipment devices upon
				documentation from the health care provider that replacement or repair is
				needed. Prior authorization for replacements is required.
(3) Equipment costing less than five hundred
				dollars does not require prior authorization, but remains subject to the
				organization's durable medical equipment guidelines.
(4) An injured employee must obtain a health
				care provider's order of medical necessity before the purchase of a mobility
				assistance device.
(5) The
				organization may require assessments to determine the functional levels of an
				injured worker who is being considered for a mobility assistance
				device.