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SB 2280

AN ACT to create and enact chapter 26.1-36.12 of the North Dakota Century Code, relating to prior authorization for health insurance; to provide for a legislative management study; to provide for a legislative management report; and to provide an effective date.

69th Legislative Assembly (2025-26) Introduced by Jeff Barta and 5 co-sponsors

Creates an ND chapter setting statewide PA standards to boost transparency, protect timely care, require qualified reviewers, and mandate a legislative study.

Filed with Secretary Of State 04/22
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Bill Summary · SB 2280

SB 2280 — Summary (North Dakota)

AN ACT to create and enact chapter 26.1‑36.12 of the North Dakota Century Code — relating to prior authorization for health insurance; to provide for a legislative management study and report; and to provide an effective date.

Main purpose and intent

SB 2280 establishes a new statutory chapter that sets statewide standards for prior authorization (PA) practices used by insurers, third‑party administrators, and other "prior authorization review organizations" for health and dental benefit plans. The bill is intended to increase transparency, standardize who may make PA decisions, protect timely access to care (including urgent and emergency care), and require reporting/study by the legislature.

Key provisions and requirements

  • Creates chapter 26.1‑36.12 NDCC with definitions covering: adverse determinations, appeals, authorization, clinical criteria, emergency/urgent services, enrollee, health care services (including dental, pharmaceuticals, durable medical equipment), "medically necessary," medication‑assisted treatment, and "prior authorization review organization."
  • Transparency and notice:
    • Prior authorization requirements, restrictions, and the written clinical criteria must be readily accessible on the PA organization’s website and explained in plain language.
    • If a PA organization implements a new or amended PA requirement, it may not implement the change until the website is updated and contracted health care providers are given written notice at least 60 days before implementation (earlier drafts proposed 120 days; 60 days appears in the adopted amendment).
  • Qualifications for reviewers:
    • All adverse determinations must be made by licensed clinicians (latest draft requires a licensed physician or licensed pharmacist; earlier drafts included physician/dentist).
    • The reviewer must have experience treating patients with the condition at issue and must make determinations under the clinical direction of the PA organization’s medical director.
    • Similar qualification requirements apply to personnel who review appeals (text truncated in available excerpts but follows same intent).
  • Scope of "prior authorization":
    • Applies to pre‑service reviews and certain post‑admission reviews; does not include routine referral processes unless the provider is acting as the PA organization.
    • Includes protections for urgent and emergency health care service reviews (definitions provided).
  • Legislative study/report:
    • The bill provides for a legislative management study and a report to the Legislative Assembly (details and timing not fully specified in excerpts).

Who is affected

  • Prior authorization review organizations: insurers, health plans, PBMs, third‑party administrators, employers who administer benefits, and HMOs/PPOs operating in ND.
  • Health care professionals and facilities required to use PA processes and to receive advance notice of changes.
  • Enrollees (patients) whose access to services may be subject to PA.
  • Self‑insured employer plans are subject if they function as a PA review organization (treatment depends on plan structure).
  • The bill excludes state medical assistance (Medicaid) and certain public employee retirement system plans in some versions (check final enacted text for exact exemptions).

Potential impacts and administrative considerations

  • Increased transparency and predictability for providers and patients (access to clinical criteria and advance notice of changes).
  • Administrative and compliance costs for PA organizations to post criteria, provide notices, and ensure appropriately‑credentialed reviewers.
  • Potentially faster or more consistent decisions for enrollees if reviewer qualifications and appeal procedures are enforced; urgent/emergency care protections intended to limit harmful delays.
  • Legislative study/report could lead to future policy changes informed by implementation data.

Procedural / timeline notes

  • The bill was introduced in the 2025 legislative session and creates a new statutory chapter; the bill text provides for an effective date (check final enrolled act for the exact effective date). The available committee drafts show the 60‑day notice requirement as a House amendment. Review the enacted chapter in the ND Century Code for the final operative language.

Compiled from official sources — confirm details with the bill’s official record.

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