State guide
North Dakota
Pick the kind of plan you have to see who to call first. North Dakota can only help with plans it regulates.
Which plan do you have? Who to call first, by coverage
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Your employer pays claims itself
North Dakota usually cannot help with these plans. Call the Employee Benefits Security Administration.
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Insurance you buy, or an employer plan bought from an insurer
Call North Dakota Insurance Department. See the at-a-glance box.
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Medicaid or children's coverage
Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in North Dakota.
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Medicare
State Health Insurance Counseling Program (SHIC), North Dakota Insurance Department gives free counseling. Or call 1-800-MEDICARE.
The short version for North Dakota
North Dakota has a state external review run by independent reviewers, with a binding decision, a filing fee capped at $25 that is refunded if you win, and a four month filing window. A new prior authorization law took effect January 1, 2026, with 72 hour decisions for urgent requests, doctor-level reviewers and automatic approval when an insurer misses a deadline. The state has no dedicated health insurance ombudsman: the Insurance Department's consumer staff and Legal Services of North Dakota are the main free helpers.
At a glance: independent review for plans North Dakota regulates
- Main regulator
- North Dakota Insurance Department · (701) 328-2440
- Independent review
- A state process (External review by an Independent Review Organization)
- Deadline to request it
- Up to 4 months after you receive notice of the denial (your insurer may allow longer).
- Cost
- Your insurer may charge a filing fee of no more than $25 (no more than $75 in a plan year); it must be refunded if the denial is reversed and waived if it causes undue hardship. The insurer pays the reviewer. For older grandfathered plans (issued before March 23, 2010) you pay the review costs if the denial is upheld.
- Decision time
- 45 days from the independent reviewer's receipt of the request; fast track: 72 hours from the reviewer's receipt of the request
Who regulates health plans
- North Dakota Insurance Department
Fully insured health plans bought from an insurance company or health maintenance organization in North Dakota. Self-funded employer plans (where the employer pays claims itself) are regulated by the U.S. Department of Labor, and states generally cannot investigate complaints about them.
Independent (external) review
- Process
- A state process. Run by North Dakota Insurance Department, which randomly assigns an independent review organization it contracts with (for plans issued March 23, 2010 or later).
- Where you file
- either
- How
- After you receive your insurer's final internal appeal decision, file a request for external review with your insurer or with the Insurance Commissioner. The Insurance Department's page does not print a request form or address; contact the Department at (701) 328-2440 or insurance@nd.gov (600 E Boulevard Ave., Bismarck, ND 58505-0320), or ask your insurer for its external review form. The independent reviewer must allow you up to five business days to send extra information.
- Which denials qualify
- Decisions based on medical necessity, appropriateness, health care setting, level of care or effectiveness (including experimental or investigational treatment), and cancellation of coverage with retroactive effect (rescission). There is no minimum dollar amount. Grandfathered plans (issued before March 23, 2010) can use external review only for whether care was medically necessary.
- Appeal to the plan first?
- Yes in most cases. You may skip the internal appeal if you and the insurer both agree, or, for plans issued March 23, 2010 or later, if you need immediate treatment and waiting could jeopardize your life or health, in which case you can ask for expedited external review right away. North Dakota law does not require grandfathered plans to offer expedited review.
Free help in North Dakota
- North Dakota Insurance Department, Consumer Assistance
State staff take complaints about fully insured health plans, explain the internal appeal and external review process, and review insurer conduct against state law; they do not decide factual disputes or provide legal representation. The toll-free line (800) 247-0560 is listed by the federal government.
Phone: (701) 328-2440
- Legal Services of North Dakota
Free legal help for low-income and older North Dakotans with an income test and an application; health is listed among its areas for seniors, so call to ask whether an insurance or Medicaid denial qualifies (phones Monday to Thursday, 9 a.m. to 3 p.m. Central).
Phone: 1-800-634-5263 (under 60) or 1-866-621-9886 (age 60 and over)
Medicare and Medicaid in North Dakota
- Medicare counseling
- State Health Insurance Counseling Program (SHIC), North Dakota Insurance Department · (888) 575-6611 . Free help with Medicare appeals.
- Medicaid agency
- North Dakota Health and Human Services (North Dakota Medicaid)
- Fair hearing deadline
- 30 days from the date the notice of action was mailed. If your Medicaid is run by a managed care plan: no later than 120 days from the date of the plan's notice upholding its denial. Your notice states the deadline that applies to you.
- Good to know
- You can appeal by phone, email, fax or mail to the Appeals Supervisor, Legal Advisory Unit: (701) 328-2311, toll free (800) 472-2622, dhslau@nd.gov, fax (701) 328-2173, 600 E. Boulevard Ave., Dept. 325, Bismarck, ND 58505-0250. Form SFN 162 (Request for Hearing) can be used but is not required. If you are in a managed care plan (for example Medicaid Expansion run by Blue Cross Blue Shield of North Dakota), you must first appeal to the plan within 60 days; to keep benefits going during the appeal, one plan's handbook says to request continuation within 10 days of the plan's appeal decision notice.
State laws that can help
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Prior authorization. Since January 1, 2026, insurers must decide prior authorization requests within 7 calendar days (72 hours if urgent), have denials made by a licensed physician or pharmacist with relevant experience, honor approvals for at least six months (twelve for chronic conditions), and services are automatically deemed authorized if the insurer misses the law's deadlines.
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Other. Insurers may not require prior authorization for emergency services or for medication-assisted treatment of opioid use disorder, and may not withdraw an authorization if care is given within 45 business days.
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Step therapy. A health plan or pharmacy benefits manager cannot require step therapy (trying other drugs first) for an FDA-approved drug prescribed for metastatic cancer when the use matches its FDA-approved uses or is supported by peer-reviewed medical literature.
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External review. Binding external review of medical necessity, experimental treatment and rescission denials is guaranteed with up to four months to ask, no minimum claim value, a filing fee capped at $25 that is refunded if you win, and a 72 hour expedited track.
Sources and what we could not confirm
- North Dakota Insurance Department: Health insurance, including External Review
- North Dakota Insurance Department: Complaints
- North Dakota Insurance Department: State Health Insurance Counseling (Medicare)
- North Dakota Century Code section 26.1-36-46 (FindLaw)
- Enrolled Senate Bill 2280 (2025): prior authorization, chapter 26.1-36.12
- North Dakota Century Code chapter 26.1-36.12 (Justia)
- Senate Bill 2248 (2025): step therapy for metastatic cancer
- North Dakota Health and Human Services: File an Appeal (Medicaid)
- N.D. Admin. Code 75-01-03-06: Time limit on appeals (Cornell Legal Information Institute)
- Blue Cross Blue Shield of North Dakota: Medicaid Expansion Handbook 2026
- Legal Services of North Dakota
- Centers for Medicare & Medicaid Services: North Dakota Consumer Assistance
- State Health Insurance Assistance Programs: North Dakota
Not confirmed (14)
- Not confirmed. externalReview.howToFile / formUrl — the Insurance Department's page says to file with the insurer or the Commissioner but prints no form, mailing address for requests, or email for external review; the contact details given are the Department's general ones. No standalone request form was found.
- The deadline to request independent review. the Department's page says external review requests must be submitted 'within four months from the date of the denial' while the statute says four months after receipt of the notice; both are shown as up to four months, so file early.
- Which denials qualify for independent review. taken from the statute (section 26.1-36-46) as read on FindLaw's copy, not an official state site; the Department's page lists the same categories for plans issued March 23, 2010 or later.
- Published results of independent review. no North Dakota external review overturn statistics were found, so null.
- The state regulators. (701) 328-2440 is printed on the Department's pages; (800) 247-0560 appears on the federal consumer assistance page and a third-party site but was not seen on a Department page, so it is attributed accordingly.
- The state regulators. the Department's page names the U.S. Department of Labor as regulator of self-funded plans and says states generally cannot investigate them; it does not say how to check whether your plan is self-funded, so jurisdictionTip is null.
- Free consumer help programs. North Dakota has no designated federal Consumer Assistance Program; the federal list names the Insurance Department. The North Dakota Attorney General's consumer protection page (the AG consumer line is (701) 328-3404) was loaded but does not list health insurance, so it is not included.
- Free consumer help programs. Legal Services of North Dakota's page lists no specific Medicaid, Medicare or insurance-denial services and no income limits.
- The Medicaid fair hearing deadline. the 30-day rule is on the Health and Human Services page; the 120-day managed care rule is in N.D. Admin. Code 75-01-03-06(4), read through the Cornell Legal Information Institute copy. The 60-day plan appeal and 10-day continuation of benefits come from one plan's handbook (Blue Cross Blue Shield of North Dakota) and were not confirmed on a state page.
- The state's Medicare counseling program. the Department's page labels the program 'State Health Insurance Assistance Program' while the federal list uses 'State Health Insurance Counseling Program (SHIC)'; the SHIC name is used.
- Not confirmed. stateLaws (prior-authorization and the emergency/opioid treatment entry) — read from the enrolled bill text of Senate Bill 2280, which sets an effective date of January 1, 2026; the codified chapter was not compared and the bill applies to commercial health benefit plans, not to Medicaid or the state employee plan.
- Not confirmed. stateLaws (step-therapy) — the metastatic cancer rule was read in the text of 2025 Senate Bill 2248, which amends section 19-02.1-16.3; the added coverage for conditions associated with metastatic cancer applies only to the state employee plan and expires June 30, 2027. A separate 2025 step therapy exception law for the state employee plan was seen only on a bill-tracking site.
- Not confirmed. stateLaws (surprise-billing, mental-health-parity, denial-notice, ai-in-utilization-review) — no North Dakota law on these topics was researched or confirmed.
- Not confirmed. stateLaws (gold-card) — no North Dakota law exempting high-approval doctors from prior authorization was found; the 'other' entry lists the specific prior authorization bans instead.