What is prior authorization?
Prior authorization (PA) means the health plan must approve certain care before it will cover it. Providers often submit requests for you, but you still have rights if PA is denied or delayed.
Overview: Prior authorizations. North Dakota-only details below.
Confirm plan type: North Dakota: Start Here.
North Dakota PA rules
Senate Bill 2280 (2025) created Chapter 26.1-36.12 of the North Dakota Century Code, effective January 1, 2026, for most fully insured health plans. Older utilization review rules in Chapter 26.1-26.4 still apply as a baseline. These laws generally do not apply to Medicare, Medicaid fee-for-service, typical self-funded ERISA plans, or North Dakota public employee retirement system plans.
Standard PA deadlines (Ch. 26.1-36.12)
- Non-urgent requests: decision within 7 calendar days after the insurer has all necessary information (26.1-36.12-05)
- Urgent health care services: within 72 hours (26.1-36.12-06)
- If the insurer misses applicable deadlines, the service is deemed authorized (26.1-36.12-13)
- Post-emergency stabilization: insurer must decide within 2 business days after notification or services are deemed authorized (26.1-36.12-07)
Who can deny and how long PA lasts
- Adverse determinations must be made by a licensed physician or pharmacist with experience treating the condition (26.1-36.12-03)
- Insurers must publish plain-language clinical criteria online (26.1-36.12-02)
- Approved PA remains valid at least 6 months (at least 12 months for chronic or long-term conditions) (26.1-36.12-10, 26.1-36.12-11)
- 60-day continuity when switching plans mid-treatment (26.1-36.12-12)
- Limited retroactive denial when care was provided within 45 business days of approval, absent fraud or similar grounds (26.1-36.12-09)
When PA is prohibited
- Emergency medical conditions — no prior authorization (26.1-36.12-07; also Ch. 26.1-26.4)
- Medication-assisted treatment for opioid use disorder — no PA (26.1-36.12-08)
Baseline utilization review (Ch. 26.1-26.4)
Utilization review agents must be certified with the Insurance Commissioner, maintain documented appeal procedures, and use physicians or licensed psychologists for adverse determinations on emergency and other covered services.
Where to look up PA rules
Insurers must disclose PA requirements under Chapter 26.1-36.12. Check your plan materials and the carrier's provider or member portal first.
Carrier links: North Dakota prior auth & internal appeals links.
Medicaid
SB 2280 does not apply to Medicaid fee-for-service the same way, but managed care plans follow federal utilization management rules. Denials use MCO appeal and fair hearing paths—see North Dakota internal appeals.
If PA is denied
Appeal the adverse determination using procedures in 26.1-36.12-14 and your plan documents.
Urgent care
Mark requests urgent when delay would seriously jeopardize life or health. The insurer must decide within 72 hours or the request is deemed authorized.
You may request expedited internal and external appeals in qualifying urgent situations.