# Title 45 — Insurance, Commissioner of

## Article 45-06 — Accident and Health Insurance

## Chapter 45-06-03.1 — Standardized Health Claim Form Model Regulation

### § 45-06-03.1-01. Definitions.

As used in this chapter:
1. "CDT-1 codes" means the current dental terminology prescribed by the American dental
association.
2. "CPT-4 codes" means the current procedural terminology published by the American medical
association.
3. "HCFA" means the health care financing administration of the United States department of
health and human services.
4. "HCFA form 1450" means the health insurance claim form published by HCFA for use by
institutional care practitioners.
5. "HCFA form 1500" means the health insurance claim form published by HCFA for use by
health care practitioners.
6. "HCPCS" means HCFA's common procedure coding system, a coding system which
describes products, supplies, procedures, and health professional services and includes the
American medical association's physician current procedural terminology, fourth edition
(CPT-4) codes, alphanumeric codes, and related modifiers. This includes:
a. "HCPCS level 1 codes" which are the American medical association's CPT-4 codes and
modifiers for professional services and procedures.
b. "HCPCS level 2 codes" which are national alphanumeric codes and modifiers for health
care products and supplies, as well as some codes for professional services not included
in the American medical association's CPT-4.
c. "HCPCS level 3 codes" which are local alphanumeric codes and modifiers for items and
services not included in HCPCS level 1 or HCPCS level 2.
7. "Health care practitioner" means:
a. An addiction counselor licensed under North Dakota Century Code chapter 43-45.
b. An audiologist licensed under North Dakota Century Code chapter 43-37.
c. A chiropractor licensed under North Dakota Century Code chapter 43-06.
d. A corporation or partnership of health care practitioners defined in this section.
e. A dentist licensed under North Dakota Century Code chapter 43-28.
f. A nurse licensed under North Dakota Century Code chapter 43-12.1.
g. A nutritionist licensed under North Dakota Century Code chapter 43-44.
h. An optometrist licensed under North Dakota Century Code chapter 43-13.

i. A pharmacist licensed under North Dakota Century Code chapter 43-15.
j. A physician licensed under North Dakota Century Code chapter 43-17.
k. A podiatrist licensed under North Dakota Century Code chapter 43-05.
l. A psychologist licensed under North Dakota Century Code chapter 43-32.
m. A social worker licensed under North Dakota Century Code chapter 43-41.
n. A physical, speech, occupational, or respiratory therapist licensed under North Dakota
Century Code chapters 43-26, 43-37, 43-40, or 43-42.
o. A home health care provider licensed under North Dakota Century Code chapter 23-17.3.
8. "ICD-9-CM codes" means the diagnosis and procedure codes in the international classification
of disease, ninth revision, clinical modifications published by the United States department of
health and human services.
9. "Institutional care practitioner" means:
a. A hospice licensed under North Dakota Century Code chapter 23-17.4.
b. A hospital licensed under North Dakota Century Code chapter 23-16, 23-17, or 23-17.1.
c. Certified rural health clinic, nursing facility, basic care facility, intermediate care facility for
the mentally retarded, and residential treatment center.
10. "Issuer" means an insurance company, fraternal benefit society, health care service plan,
health maintenance organization, or third-party administrator, or any other entity reimbursing
the costs of health care expenses.
11. "J512 form" means the uniform dental claim form approved by the American dental
association for use by dentists.
12. "Medicare" means the Health Insurance for the Aged Act, title XVIII of the Social Security
Amendments of 1965, as then constituted or later amended.
13. "Medical assistance or Medicaid" means title XIX of the federal Social Security Act [42 U.S.C.
1396, et seq.] as then constituted or later amended.
14. "Prescription universal claim form" means the uniform claim form used by pharmacists.
15. "Revenue codes" means the codes established for use by institutional care practitioners by
the national uniform billing committee.
History: Effective September 1, 1994.
General Authority: NDCC 26.1-36-37.1, 26.1-36-38
Law Implemented: NDCC 26.1-36-37.1
### § 45-06-03.1-02. Applicability and scope.

1. Except as otherwise specifically provided, the requirements of this chapter apply to issuers,
health care practitioners, and institutional care practitioners.
2. Nothing in this chapter prevents an issuer from requesting additional information that is not
contained on the forms required under this chapter to determine eligibility of the claim for
payment if required under the terms of the policy or certificate issued to the claimant.

History: Effective September 1, 1994.
General Authority: NDCC 26.1-36-37.1, 26.1-36-38
Law Implemented: NDCC 26.1-36-37.1
### § 45-06-03.1-03. General provisions.

1. Health care practitioners and institutional care practitioners shall file claims in a manner
consistent with the requirements of this chapter. Claims filed in paper form must be printed on
eight and one-half by eleven-inch [21.59 by 27.94-centimeter] paper.
2. Issuers shall accept forms submitted in compliance with this chapter for the processing of
claims.
3. Health care practitioners, institutional care practitioners, and issuers shall:
a. Use and accept the most current editions of the HCFA form 1450, HCFA form 1500,
prescription universal claim form, or J512 form and most current instructions for these
forms in the billing of patients or their representatives filing claims with issuers.
b. Modify their billing and claim reimbursement practices to encompass the coding changes
for all billing and claim filing by the effective date of the changes set forth by the
developers of the forms, codes, and procedures required under this chapter.
4. Issuers may not require health care practitioners to use any coding system for the initial filing
of claims for health care services other than the following:
a. HCPCS codes.
b. ICD-9-CM codes.
c. Revenue codes.
5. Issuers may not require health care practitioners to use any other descriptor with a code or to
furnish additional information with the initial submission of a HCFA form 1500 except under the
following circumstances:
a. When the procedure code used describes a treatment or service that is not otherwise
classified; or
b. When the procedure code is followed by the CPT-4 modifier 22, 52, or 99.
History: Effective September 1, 1994.
General Authority: NDCC 26.1-36-37.1, 26.1-36-38
Law Implemented: NDCC 26.1-36-37.1
