Utilization Review Agent

Health Care Service Utilization Review is governed by the provisions of N.D.C.C. § 26.1-26.4 and N.D. Admin. Code § 45-06-10.

In order to conduct a utilization review in North Dakota, a utilization review agent must certify to the Insurance Commissioner that the agent is in compliance with the minimum standards set out in N.D.C.C. § 26.1-26.4-04. The utilization review agent must submit a complete application consisting of the following requirements:

  • Utilization Review Filing Report (SFN 18332)
  • Utilization Review Agent Certification (SFN 18378)
  • A description of the appeal procedures for utilization review determinations.
  • A list of the third-party payers for whom the private review agent is performing utilization review in the state.
  • Copy of URAC or NCQA Accreditation - specifying the program, if applicable.
  • Provide the name of the physician, practitioner or psychologist that will be conducting the utilization reviews (North Dakota board certified).

The North Dakota Insurance Department will issue a letter of certification if the application is approved. An application may be filed at any time throughout the year. All applications should be directed to the Department.

Any material changes in the information submitted to the Department, such as change in Federal Employer Identification Number (FEIN), name, address/contact, change in control, conversion, etc. must be filed with the Commissioner within 30 days of the change.

Annual Renewal Requirement

The certification form, Utilization Review Agent Certification (SFN 18378), must be filed with the Insurance Commissioner on or before March 1 of each calendar year.

Utilization review agents can review their status through the National Association of Insurance Commissioners (NAIC) State Based Systems (SBS).