§ 50-24.1-29 — Insurers to provide certain information to the department

North Dakota § 50-24.1-29

• Jurisdiction: North Dakota
• Title 50: Public Welfare
• Ch. 50-24.1: Medical Assistance for Needy Persons

Text

1. For purposes of this section:
a. "Department" means the department of health and human services or its agent.
b. "Health insurer" includes self-insured plans, group health plans as defined in
section 607(1) of the Employee Retirement Income Security Act of 1974
[29 U.S.C. 1167(1)], service benefit plans, managed care organizations,
pharmacy benefit managers, or other parties that legally are responsible by
statute, contract, or agreement for payment of a claim for a health care item or
service.
2. a. As a condition of doing business in this state, health insurers shall provide to the
department upon its request and in a manner prescribed by the department
information about individuals who are eligible for medical assistance so the
department may determine during what period the individual or the individual's
spouse or dependents may be or may have been covered by a health insurer and
the nature of the coverage provided by the health insurer, including the name,
address, identifying number of the plan, and duration of the health insurance
coverage. Notwithstanding any other provision of law, every health insurer, not
more frequently than twelve times in a year, shall provide to the department upon
its request information, including automated data matches conducted under the
direction of the department, as necessary, to:
(1) Identify individuals covered under the insurer's health benefit plans who are
also recipients of medical assistance;
(2) Determine the period during which the individual or the individual's spouse
or the individual's dependents may be or may have been covered by the
health benefit plan; and
(3) Determine the nature of the coverage.
b. The insurer must provide the information required in this subsection to the
department at no cost if the information is in a readily available structure or
format. If the department requests the information in a structure or format that is
not readily available, the insurer may charge a reasonable fee for providing the
information, not to exceed the actual cost of providing the information.
3. To facilitate the department in obtaining the information required by this section, a
health insurer shall:
a. Cooperate with the department to determine whether a medical assistance
recipient may be covered under the insurer's health benefit plan and is eligible to
receive benefits under the health benefit plan for services provided under the
medical assistance program.
b. Respond to the request for information within ninety days after receipt of written
proof of loss or claim for payment for health care services provided to a recipient
of medical assistance who is covered by the insurer's health benefit plan.
c. Accept the department's right of recovery, entitlement to payment, and the
assignment to the department of any right of an individual or other entity to
payment from a liable third party for an item or service for which payment has
been made under the state medical assistance plan.
d. Respond to any inquiry by the department within sixty days regarding a claim for
payment for any health care item or service that is submitted no later than three
years after the date of the provision of the health care item or service.
e. Agree not to deny a claim submitted by the department solely on the basis of the
date of submission of the claim, the type of format of the claim form, or a failure to
present proper documentation at the point of sale that is the basis of the claim if:
(1) The claim is submitted by the department within the three-year period
beginning on the date on which the item or service was furnished; and
(2) Any action by the department to enforce its rights with respect to such claim
is commenced within six years of the department's submission of the claim.

f. Accept Medicaid's authorization that the item or service is covered under the
state plan as if the authorization were the prior authorization made by the third
party for the item or service.
g. Agree to not deny a claim submitted by the department for failure to obtain prior
authorization for an item or service.
4. A health insurer is prohibited, in enrolling an individual or on the individual's behalf,
from taking into account that the individual is eligible for or is provided medical
assistance.
5. The department may not use or disclose any information provided by the insurer other
than as permitted or required by law. The insurer may not be held liable for the release
of insurance information to the department or a department agent if the release is
authorized under this section.