N.D. Admin. Code § 45-06-11-05
1. 1. A health carrier is required, within a reasonable time, to make a determination regarding the individual's qualifying previous coverage and notify the individual of the determination in accordance with this section.
2. 2. A health carrier seeking to impose a preexisting condition exclusion is required to disclose to the individual in writing its determination of any preexisting condition exclusion period that applies to the individual and the basis for such determination, including the source and substance of any information on which the health carrier relied. In addition, the health carrier is required to provide the individual with a written explanation of any appeal procedures established by the issuer and with a reasonable opportunity to submit additional evidence of coverage. Nothing in this section prevents a health carrier from modifying an initial determination qualifying previous coverage if it determines that the individual did not have the claimed qualifying previous coverage, provided that:
1. a. A notice of reconsideration is provided to the individual; and
2. b. Until the final determination is made, the health carrier, for purposes of approving access to medical services, acts in a manner consistent with the initial determination.
History: Effective December 1, 1997.
General Authority: NDCC 26.1-08-12(4), 26.1-36.3-06(3)(b), 26.1-36.4-04
*IMPORTANT--This certificate provides evidence of your prior health coverage. You may need to furnish this certificate if you become eligible under a group health plan that excludes coverage for certain medical conditions that you have before you enroll, if medical advice, diagnosis, care, or treatment was recommended or received for the condition during the six months before your enrollment in the new plan. If you become covered under another group health plan, check with the plan administrator to see if you need to provide this certificate. You may also need this certificate to establish your right to buy coverage for yourself or your family, with no exclusion for previous medical conditions, if you are not covered under a group health plan.
1. Date of this certificate: _______
2. Name of policyholder: _______
3. Identification number of policyholder: _______
4. Name of any dependents to which this certificate applies:
5. Name, address, and telephone number of issuer responsible for providing this certificate:
6. For further information, call: _______
7. If all individuals identified in lines 2 and 4 have at least 18 months of creditable coverage (disregarding periods of coverage before a 63-day break), check here _______ and skip lines 8 and 9.
8. Date coverage began: _______
9. Date that a substantially completed application was received from this policyholder:
10. Date coverage ended: ____ (or check here if coverage is continuing as of the date of this certificate: ____).
NOTE: Separate certificates will be furnished if information is not identical for the participant and each beneficiary.
*IMPORTANT--This certificate provides evidence of your prior health coverage. You may need to furnish this certificate if you become eligible under a group health plan that excludes coverage for certain medical conditions that you have before you enroll. This certificate may need to be provided if medical advice, diagnosis, care, or treatment was recommended or received for the condition within the six-month period prior to your enrollment in the new plan. If you become covered under another group health plan, check with the plan administrator to see if you need to provide this certificate. You may also need this certificate to buy, for yourself or your family, an insurance policy that does not exclude coverage for medical conditions that are present before you enroll.
1. Date of this certificate: _______
2. Name of group health plan: _______
3. Name of participant: _______
4. Identification number of participant: _______
5. Name of any dependents to which this certificate applies:
6. Name, address, and telephone number of plan administrator or issuer responsible for providing this certificate: _______
7. For further information, call: _______
8. If the individuals identified in line 3 and line 5 have at least 18 months of creditable coverage (disregarding periods of coverage before a 63-day break), check here _______ and skip lines 9 and 10.
9. Date waiting period or affiliation period (if any) began: _______
10. Date coverage began: _______
11. Date coverage ended: ____ (or check here if coverage is continuing as of the date of this certificate: ____).
NOTE: Separate certificates will be furnished if information is not identical for the the participant and each beneficiary.