What is an internal appeal?
An internal appeal asks the health plan to reconsider a denial—when the plan says care is not medically necessary, experimental, or investigational, or denies PA or a claim.
This is different from external review, where NCDOI assigns an independent review organization (IRO) after internal review is complete (with limited urgent exceptions).
General walkthrough: Appeals roadmap.
North Dakota appeal timelines
Prior authorization appeals (Ch. 26.1-36.12-14)
SB 2280 requires insurers to maintain written procedures for appeals of adverse PA determinations, reviewed by qualified clinicians per 26.1-36.12-04. Follow the deadlines in your denial notice and plan documents.
Utilization review (Ch. 26.1-26.4)
Certified utilization review agents must maintain documented appeal procedures and cannot discriminate against providers who help patients appeal.
Marketplace and ACA individual plans
Most non-grandfathered plans sold in North Dakota follow federal internal appeal standards summarized by NCDOI:
- File within 180 days of the denial notice in most cases (HealthCare.gov)
- Pre-service appeals: decision within 30 days
- Post-service appeals: decision within 60 days
- Expedited appeals: as fast as the medical condition requires, often within 72 hours
Grandfathered plans
Plans issued before March 23, 2010 may follow different appeal schedules. NCDOI notes grandfathered external reviews may use other peer review organizations with different timing.
How to file
- Read the denial for appeal instructions and deadlines.
- Submit in writing when possible—include your member ID, claim number, and clinical support.
- Request expedited review if delay would cause serious harm.
- Keep copies of everything sent and the date sent.
Carrier links: North Dakota prior auth & internal appeals links.
Evidence that helps
- Treating clinician letter on medical necessity
- Insurer's published clinical criteria (Ch. 26.1-36.12-02)
- Peer-reviewed literature for experimental/investigational disputes
Medicaid appeals
Medicaid managed care requires an MCO appeal before a state fair hearing in most cases:
- MCO appeal: typically 60 calendar days from the adverse benefit determination (federal Medicaid managed care rules)
- MCO must resolve within about 30 days (extensions possible with notice)
- State fair hearing: request to ND Health and Human Services — often 90–120 days from the MCO resolution notice under federal rules; some county Medicaid decisions allow 30 days from the notice of action
After internal appeal
If you receive a final denial, request external review within four months (NCDOI — health insurance).
Next: North Dakota external review.