The definitions found in North Dakota Century Code title 65 apply to terms contained in this title. In addition, unless the context otherwise requires, for purposes of sections 92-01-02-27 through 92-01-02-48:

1. "Bill audit" means the review of medical bills and associated medical records by the organization or the managed care vendor, including review for duplications, omissions, actual delivery of billed services and items, accuracy of charges and associated coding, coding

documentation guidelines, coverage, concurrent billing for covered and noncovered services, and application of fee schedules.

1. 2. 'Case management' means the ongoing coordination of medical services provided to an injured employee, including:

1. a. Developing a treatment plan to provide appropriate medical services to an injured employee.

2. b. Systematically monitoring the treatment rendered and the medical progress of the injured employee.

3. c. Assessing whether alternative medical services are appropriate and delivered in a cost-effective manner based upon acceptable medical standards.

4. d. Ensuring the injured employee is following the prescribed medical plan.

5. e. Formulating a plan for keeping the injured employee safely at work or expediting a safe return to work.

2. 3. 'Consulting health care provider' means a licensed health care provider who examines an injured employee, or the injured employee's medical record, at the request of the primary health care provider to aid in diagnosis or treatment. A consulting health care provider, at the request of the primary health care provider, may provide specialized treatment of the compensable injury and give advice or an opinion regarding the treatment being rendered or considered for an injured employee's injury.

3. 4. 'Debilitating side effects' means an adverse effect to a treatment or medication which in and of itself precludes return to employment or participation in vocational rehabilitation services.

4. 5. 'Elective surgery' means surgery that may be required in the process of recovery from an injury or illness but need not be done as an emergency to preserve life, function, or health. Pain, of itself, does not constitute a surgical emergency.

5. 6. 'Emergency' means a medical condition that manifests itself by symptoms of sufficient severity, which may include severe pain, to cause a prudent layperson possessing an average knowledge of health and medicine to reasonably conclude that immediate medical treatment is required to avoid serious impairment of a bodily function, or serious dysfunction of any body part, or jeopardizing the person's life.

6. 7. 'Fee schedule' means the organization's rules and maximum payment amounts that govern how health care providers are reimbursed.

7. 8. 'Functional capacity evaluation' means an objective, directly observed, measurement of an injured employee's ability to perform a variety of physical tasks combined with subjective analyses of abilities by the injured employee and the evaluator. A physical tolerance screening and a Blankenship's functional evaluation are functional capacity evaluations.

8. 9. 'Improved pain control' means the effectiveness of a treatment or medication which results in at least thirty percent reduction in pain scores.

9. 10. 'Increase in function' means the effectiveness of a treatment or medication which results in either a resumption of activities of daily living, a return to employment, or participation in vocational rehabilitation services.

10. 11. 'Managed care' means services performed by the organization or a managed care vendor, including prior authorization or preservice reviews, disability management services, case

management services, ambulatory reviews, retrospective reviews, preadmission reviews, and medical bill audit.

1. 12. 'Managed care vendor' means a vendor that is retained by the organization to provide managed care services.

2. 13. 'Medical service' means a medical, surgical, chiropractic, psychological, dental, hospital, nursing, ambulance, and other related or ancillary service, including physical and occupational therapy, medications, durable medical equipment, and physical restoration and diagnostic services, or a service outlined in section 92-01-02-30.

3. 14. 'Medical service provider' means an allied health care professional, hospital, medical clinic, or vendor of medical services.

4. 15. 'Medically stationary' means the 'date of maximum medical improvement' as defined in North Dakota Century Code section 65-01-02 has been reached.

5. 16. 'Notice of nonpayment' means the form by which an injured employee is notified of charges denied by the organization which are the injured employee's personal responsibility.

6. 17. 'Pharmacy services' means services rendered by a pharmacist in pharmaceutical care, selection, counseling, dispensing, use, administration, prescription monitoring, medication therapy management, disease state management, drug utilization evaluation or review, vaccination, testing, or collaborative therapy management provided in a pharmacy, clinic, hospital or medical institution.

7. 18. 'Primary health care provider' means a health care provider who is primarily responsible for the treatment of an injured employee's compensable injury.

8. 19. 'Prior authorization' or 'preservice review' means the evaluation by the organization or a managed care vendor of a proposed medical service for medical necessity, appropriateness, and efficiency prior to the services being performed based on medically accepted standards and an objective evaluation of the medical services.

9. 20. 'Remittance advice' means the form used by the organization to inform payees of the reasons for payment, reduction, or denial of medical services.

10. 21. 'Retrospective review' means the organization's or a managed care vendor's review of a medical service for medical necessity, appropriateness, and efficiency after treatment has occurred.

11. 22. 'Special report' means an allied health care professional's written response to a specific request from the organization for information, including information on causation, aggravation, preexisting conditions, and clarification of complex medical conditions, requiring the creation of a new document or the previously unperformed analysis of existing data. The explanatory reports required for procedures designated as 'by report' under section 92-01-02-27 are not special reports.

12. 23. 'Utilization review' means the provision of prior authorization or preservice review, the review of medical patterns and trends, and the analysis of the appropriateness of medical services provided to an injured employee based on medically accepted standards and an objective evaluation of the medical services.

13. 24. 'Work hardening' or 'work conditioning' means an individualized, medically prescribed and monitored, work-oriented treatment process which involves the injured employee participating in an exercise program or simulated or actual work tasks that are structured and graded to

progressively increase physical tolerances, stamina, endurance, and productivity to return the injured employee to any level of work or a specified job.

History: Effective January 1, 1994; amended effective October 1, 1998; January 1, 2000; May 1, 2002; April 1, 2014; April 1, 2016; April 1, 2020; January 1, 2022; January 1, 2024; January 1, 2026.

General Authority: NDCC 65-02-08, 65-02-20, 65-05-07

Law Implemented: NDCC 65-02-20, 65-05-07