# Title 45 — Insurance, Commissioner of

## Article 45-06 — Accident and Health Insurance

## Chapter 45-06-10 — Utilization Review

### § 45-06-10-01. Definition.

For purposes of this chapter "licensed practitioner" includes dentist, chiropractor, psychologist, and
optometrist.
History: Effective September 1, 1994.
General Authority: NDCC 26.1-01-08, 28-32-02
Law Implemented: NDCC 26.1-26.4-04
### § 45-06-10-02. Subsequent determination after initial appeal.

1. After an initial appeal to reverse a determination regarding hospital, medical, or other health
care services is unsuccessful, a subsequent determination which may result in denial of
third-party reimbursement or denial of precertification for service must include the evaluation,
findings, and concurrence of a physician or licensed practitioner trained in the relevant
specialty to make a final determination that care provided or to be provided was, is, or may be
medically inappropriate.
2. A physician or licensed practitioner must hold a valid, current professional license issued by
an appropriate professional board.
3. Compensation of a physician or licensed practitioner giving an opinion in regard to any
determination under subsection 1 may not be dependent in any way upon the result of the
final determination.
History: Effective September 1, 1994.
General Authority: NDCC 26.1-01-08, 28-32-02
Law Implemented: NDCC 26.1-26.4-04
