This bill introduces a new chapter, 26.1-36.12, in the North Dakota Century Code that establishes regulations for prior authorization processes in health insurance. It defines essential terms such as "adverse determination," "authorization," and "medically necessary," and mandates that prior authorization review organizations make their requirements accessible to both enrollees and healthcare professionals. The bill requires that any new or amended prior authorization requirements be communicated to healthcare providers at least sixty days prior to implementation. It also stipulates that all adverse determinations must be made by licensed physicians or pharmacists with relevant experience, and appeals must be reviewed by qualified medical professionals.

Additionally, the legislation sets specific timelines for prior authorization decisions, including a seven-day response for nonurgent requests and a seventy-two-hour response for urgent care situations. It prohibits prior authorization for emergency medical services and medication-assisted treatment for opioid use disorder, while allowing enrollees and their healthcare providers a minimum of two business days to notify the prior authorization review organization following an emergency admission. The bill further establishes that prior authorizations cannot be revoked or limited if care is provided within 45 business days, unless fraud is involved, and that they remain valid for at least six months, or 12 months for chronic conditions. It also mandates annual reporting to the insurance commissioner on prior authorization requests and outcomes, with an effective date set for January 1, 2026.