How to appeal a health insurance denial in North Dakota
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. North Dakota lets you ask an independent reviewer to decide, through North Dakota Insurance Department. The deadline to ask: within four months from the date of the denial, unless your insurer allows a longer period.
Does this apply to you? State external review covers plans regulated by North Dakota: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in North Dakota
Within four months from the date of the denial, unless your insurer allows a longer period
For urgent cases the IRO must decide within 72 hours of receiving the request. You can ask to bypass the insurer's internal appeal, and state law lets you file an expedited external review while an internal appeal is still being processed.
Insurer may charge a filing fee of up to $25 (refunded if the denial is reversed, waived for undue hardship, capped at $75 per plan year); the insurer pays the IRO
State-regulated plans (insurance bought in North Dakota or through an employer that buys insurance). Self-funded employer plans use the federal process.
File the written request with your insurer or with the Insurance Commissioner (600 E. Boulevard Ave., Bismarck, ND 58505-0320); the Department randomly assigns an IRO. The Department's site lists 701-328-2440; CMS and NAIC directories also list an in-state-only toll-free line, 800-247-0560 (TTY 800-366-6888). Grandfathered plans (issued before March 23, 2010) follow older rules and may bill you for the review if the denial is upheld.
Who to contact
- North Dakota Insurance Department
- External review information and forms
- Consumer help line: 701-328-2440
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in North Dakota?
Within four months from the date of the denial, unless your insurer allows a longer period
Can I get a fast external review in North Dakota?
For urgent cases the IRO must decide within 72 hours of receiving the request. You can ask to bypass the insurer's internal appeal, and state law lets you file an expedited external review while an internal appeal is still being processed.
Does external review cost anything in North Dakota?
Insurer may charge a filing fee of up to $25 (refunded if the denial is reversed, waived for undue hardship, capped at $75 per plan year); the insurer pays the IRO
Do North Dakota’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- North Dakota Insurance Department - Health (External Review)
External review requests must be submitted within four months from the date of the denial unless your insurer allows a longer period of time.
- N.D. Cent. Code 26.1-36-46 (External review procedures)
A claimant must have up to four months after receipt of notice of an adverse benefit determination to request external review.
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.