North Dakota routes the appeal by the age of the plan

Two tracks, split by March 23, 2010

The split is by plan vintage, not by the kind of denial. A policy issued on or after March 23, 2010 is non-grandfathered and its external review is handled by an independent review organization contracted by the Insurance Department; these organizations are nationally certified, which is the state's assurance that reviewers are unbiased, qualified and independent. A policy issued before that date is grandfathered, and the review goes instead to North Dakota Health Care Review, Inc., another peer review organization meeting the requirements of section 1152 of the Social Security Act, or any person designated by the Insurance Commissioner.

Four months, and a fee that is capped

The request is submitted within four months from the date of the denial, unless the insurer allows a longer period. North Dakota is also one of the states that permits a charge for the process: an insurance company, nonprofit health service corporation or HMO may require the consumer to pay a nominal filing fee, and that fee may not exceed $25.

• Filing window: 4 months from the date of denial, unless the insurer allows longer.
• Filing fee: nominal, and capped at $25.
• Decision: up to 45 days once the request is found eligible.

When the internal appeal can be skipped

In most cases the insurer's internal grievance procedure has to be completed first. North Dakota keeps one exception, and it is consent-based rather than automatic: the internal process does not have to be completed if both the covered person and the insurer agree to proceed directly to external review because immediate medical care is needed.

The prior-authorization law arriving in 2026

Senate Bill 2280 created a new chapter of the Century Code, 26.1-36.12, on prior authorization for health insurance. It was signed on April 23, 2025 and takes effect on January 1, 2026, and its provisions are unusually direct about consequences.

• If a prior authorization review organization fails to comply with the deadlines and other requirements of the chapter, the health care services subject to review are automatically deemed authorized.
• A prior authorization is valid for at least six months after the provider receives it, with extended validity for chronic or long-term care conditions.
• A provider has the benefit of the authorization where care is provided within 45 business days of receiving it, absent evidence the authorization was based on fraud.

What the reviewer is being asked

External review exists to put the dispute in front of experts with no affiliation to the insurer. That framing matters when you write: the reader is not the plan's own medical director being asked to reconsider, but an outside clinician being asked whether the service met the standard. Argue to the clinical record and the published criteria, not to the plan's internal reasoning.

For North Dakota practices

Two things are worth confirming before anything is drafted. First, the plan's issue date, because it decides which reviewer hears the case. Second, whether the insurer is charging the filing fee, since the $25 cap means an invoice above it is wrong on its face. And from January 2026, log the date a prior-authorization request was submitted as carefully as the clinical detail — under the new chapter, that date is what makes a deemed authorization arguable.