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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyNorth Dakota LTC Denial Policy Update | OpenPayer
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    CurrentNorth Dakota Insurance DepartmentPolicy 2023-1

    Denial of Long-Term Care or Nursing Home Benefits Based on Facility Licensure

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    Applies to health insurance companies issuing or administering long-term care policies. Requires case-by-case review of medical records and level of care before denial and prohibits denials based solely on facility type.

    Policy Summary
    PayerNorth Dakota Insurance Department
    PolicyDenial of Long-Term Care or Nursing Home Benefits Based on Facility Licensure
    Policy CodePolicy 2023-1
    Change TypeAdministrative clarification and review requirement
    Effective DateMarch 1, 2023
    Next Review DateUntil rescinded
    Key ActionBefore denying a long-term care claim or other benefit, review the patient's medical records and level of care on a case-by-case basis.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    AllCovered insurers and administrators
    Case-by-caseRequired review before denial
    ProhibitedFacility-type-only denial
    ADLs or cognitive impairment

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Level-of-care examples
    26.1-04-03(9)Legal provision cited
    Until rescindedBulletin duration

    Facility-Type Denial Standard

    Required review and prohibited facility-type-only denial

    Before denying a long-term care claim or other benefit, the insurer or administrator must complete a case-by-case review. A denial may not be based solely on facility type.

    Required before denial

    • The patient's medical records are reviewed and considered.
    • The level of care being received is reviewed and considered.
    • The determination is made on a case-by-case basis before denial.
    A claim or benefit must not be denied solely because care is provided in a particular facility type, including a basic care facility.

    Examples of level-of-care indicators to consider

    • Activities of daily living standards.
    • Cognitive impairment criteria.

    Required Claim Review Actions

    Documentation Required

    Conduct a case-by-case clinical and level-of-care review

    Before denying a long-term care claim or other benefit, review and consider the patient's medical records and the level of care being received on a case-by-case basis.

    Documentation Required

    Evaluate level-of-care criteria

    When determining benefits, consider applicable indicators of the level of care the patient is receiving, including activities of daily living standards and cognitive impairment criteria.

    • Review activities of daily living standards.
    • Consider cognitive impairment criteria.
    Policy Summary
    PayerNorth Dakota Insurance Department
    PolicyDenial of Long-Term Care or Nursing Home Benefits Based on Facility Licensure
    Policy CodePolicy 2023-1
    Change TypeAdministrative clarification and review requirement
    Effective DateMarch 1, 2023
    Next Review DateUntil rescinded
    Key ActionBefore denying a long-term care claim or other benefit, review the patient's medical records and level of care on a case-by-case basis.
    SourceLink
    On This Page
    Facility-Type Denial StandardRequired Claim Review Actions
    Denial Risk

    Do not deny solely based on facility type

    Do not deny a claim or benefit solely because the insured receives care in a particular facility type, including a basic care facility. The Department considers facility-type-only denials a violation of the Unfair Claim Settlement Practices Act.