§ 26.1-36-44 — Independent external review

This section applies to grandfathered health plans. "Grandfathered health plan" has the
meaning stated in the Patient Protection and Affordable Care Act [Pub. L. 111-148], as amended
by the Health Care and Education Reconciliation Act of 2010 [Pub. L. 111-152]. Every insurance
company, nonprofit health service corporation, and health maintenance organization that offers

an accident and health line of insurance shall establish and implement an independent external
review mechanism to review and determine whether medical care rendered under the line of
insurance was medically necessary and appropriate to the claim as submitted by the provider.
For purposes of this section, "independent external review" means a review conducted by the
North Dakota health care review, inc., another peer review organization meeting the
requirements of section 1152 of the Social Security Act, or any person designated by the
commissioner to conduct an independent external review. A determination made by the
independent external reviewer is binding on the parties. Costs associated with the independent
external review are the responsibility of the nonprevailing party. A provider may not use an
independent external review under this section unless the provider first has exhausted all
internal appeal processes offered by the insurance company, nonprofit health service
corporation, or health maintenance organization. The insurance commissioner shall take steps
necessary to ensure compliance with this section. If federal laws or rules relating to independent
external review are amended, repealed, or otherwise changed, the insurance commissioner
shall adopt rules to ensure the independent external review procedure is in compliance with and
substantively equivalent to the federal requirements.