Written by a parent, not a doctor. Nothing here is medical advice.

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North Dakota program

An outside review when your plan says no

An independent reviewer can reconsider a health plan’s refusal to cover care.

What it is

An independent reviewer can reconsider a health plan’s refusal to cover care.

A final refusal from the insurer is not always the last word. On a plan North Dakota regulates, a reviewer independent of the plan decides. A plan where the employer pays its own claims uses a federal route instead; one question to HR settles which.

Eligibility rules
  • The state route covers insured group and individual policies, nonprofit health service corporations and health maintenance organizations.
  • The request period is four months after the plan’s final internal decision.
What you get
  • An independent decision that binds the plan.
  • A decision within 45 days, or 72 hours for an urgent review.
What the help includes
  • The care team’s letter explains medical necessity and why delay would harm your child when urgent review is needed.
If you decide to apply
  1. Ask the social worker and oncology team to review the final denial and the plan’s outside-review instructions.
  2. If you decide to request review, the denial notice and Insurance and Securities Department confirm the submission route. The request may go to the insurer or commissioner under the applicable process; keep proof of receipt.

Your insurer and North Dakota Insurance and Securities Department · Official page ↗

After you ask
  • The independent reviewer sends the outcome. The standard clock is 45 days and the urgent clock is 72 hours.
Good to know

Most private self-funded employer plans fall outside this state process. They have a separate federal rights conversation.

Other details
  • You have four months from the final denial to ask. Urgent cases can skip the plan's own appeal. The reviewer decides within 45 days, or 72 hours when urgent. The plan can charge up to $25 per review, waived for hardship.
Official sources
Ask your social worker

“If our plan denies treatment, could an outside review change that decision? What would it involve, and could you help us request the right review if needed?”

Why I’m asking: I want a fair review without missing the deadline.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

File within four months of the final decision and ask for expedited review if it is urgent.

Your social worker

The oncology team writes why the treatment is needed and why a delay would harm your child.

The care team

A letter of medical necessity, and a statement about urgency.

Who decides
An independent reviewer outside the plan.
Ask your social worker
“The plan has refused and the internal appeal is finished. Can we file for external review, and ask for it to be expedited?”

How to apply

First step: Keep the final denial letter, and ask the insurer in writing for external review within four months.

  1. Finish the plan’s own appeal and keep the final decision letter.
  2. File for external review within four months.
  3. Ask for the expedited route by name if waiting would harm your child.

Official application / program page ↗

Where it starts: Ask the insurer in writing for external review, and copy the Insurance and Securities Department.

What to gather

  • The denial letters
  • The letter of medical necessity from the oncology team
  • The plan documents

How long: For eligible non-grandfathered plans, generally 45 days or 72 hours when expedited; other policy types need separate review.

Clock: File within four months of the plan’s final internal decision.

What a yes looks like

A reviewer’s decision the plan has to follow.

What a no looks like, and the next move

Check whether the reason was the plan type or the deadline; ask the Insurance Department either way.

Watch out

  • Most large employers use self-funded plans, which sit outside this route. Ask HR which kind yours is.
  • The clock is four months from the plan’s final decision.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 11, 2026.

What it is worth

For eligible non-grandfathered-plan denials: generally four months to request review, 45 days for a standard decision or 72 hours when urgent.

  • $4 — Window to file after the final internal decision
  • $45 — Standard decision time
  • $72 — Expedited decision time

Legal protection: An independent decision that binds the plan

What it costs the family: Nothing.

The eligibility facts, as published

Plan type
state-regulated plans: insured group and individual policies, nonprofit health service corporations and health maintenance organisations; most private self-funded plans are outside state regulation
Timing
generally after the final internal decision, with applicable exhaustion exceptions and urgent concurrent review
Statute
NDCC ch. 26.1-36

The trap: Ask for the expedited route by name when a delay would harm your child. Four months is the filing window, and it is months, not a number of days you can count loosely.

Where I read this

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