North Dakota just made it harder for insurers to deny your doctor’s orders

North Dakota puts new rules on insurers

North Dakota has a new law that changes how insurance companies handle prior authorization, the process patients must go through before their insurer will cover certain treatments or medications.

Gov. Kelly Armstrong signed Senate Bill 2280 on April 23, 2025, and it took effect Jan. 1, 2026. The bill passed the House 93-0 and the Senate 43-3. Sen. Scott Meyer of Grand Forks led the effort.

Prior authorization causes real delays

Prior authorization means a patient needs insurer approval before getting a procedure, medication, or treatment covered.

Insurers say it controls costs and keeps care appropriate. But doctors and patient advocates say it has grown far beyond that.

Before this law, North Dakota was one of only a few states with no statewide oversight of the process, according to Essentia Health.

That left patients with little protection when insurers took their time or said no.

Insurers must now respond within a deadline

One of the biggest changes is timing. Insurers must now respond to non-urgent prior authorization requests within seven calendar days.

For urgent requests, the deadline is 72 hours. The clock starts once the insurer has everything it needs to make a decision.

Miss those deadlines? The request is automatically approved. That automatic approval rule puts real pressure on insurers to move fast.

Only licensed doctors can say no

Under the new law, only a licensed physician or licensed pharmacist can deny a prior authorization request. That reviewer must also have experience treating the specific condition involved.

Advocates say this effectively bars AI systems, algorithms, and insurance company analysts from making denial decisions. The bill does not name AI directly, but requiring a licensed professional rules it out in practice.

Emergency and addiction care get extra protection

The law bans prior authorization for emergency medical services entirely. It also bans prior authorization for medication-assisted treatment for opioid addiction.

After an emergency hospital admission, patients and providers have at least two business days to notify the insurer.

The North Dakota SB 2280 enrolled bill text spells out that if an insurer does not decide on post-emergency services within two business days, those services are automatically approved.

Approvals now last longer and travel with patients

Once an insurer approves a prior authorization, that approval stays valid for at least six months. For chronic or long-term conditions, it lasts at least 12 months.

Insurers cannot pull an approval after the fact if care happens within 45 business days, unless there is evidence of fraud.

Patients who switch insurance plans also get a break. Their new insurer must honor the old approval for at least 60 days.

Doctors spent hours fighting insurers every week

A coalition of 20 health care and patient advocacy organizations, led by Essentia Health, pushed for the bill.

The groups represented physicians, pharmacists, hospitals, physical therapists, and advocates for seniors, children, and cancer patients.

Dr. Stefanie Gefroh of Essentia Health said some physicians were spending up to 14 hours a week trying to justify medical decisions to insurers.

Bismarck resident Susan Finneman testified she nearly missed critical spinal surgery because of insurance delays.

Most appeals win, but few patients ever appeal

A KFF analysis of Medicare Advantage prior authorization data from 2022 found that about 83% of appealed denials were overturned.

But only about one in 10 denials were ever appealed. Many patients do not know they can appeal, or they find the process too hard to navigate.

Supporters of the law say those numbers show that many denials were unnecessary and simply delayed care patients would have received anyway.

Insurers pushed back but lost the vote

Insurance company representatives testified against the bill, arguing it would raise costs. America’s Health Insurance Plans said prior authorization is a proven tool to keep care safe and evidence-based.

The group cited research estimating that roughly a quarter of all medical spending, about $340 billion a year, goes toward wasteful or low-value care. Despite that opposition, the bill passed with near-unanimous bipartisan support in both chambers.

The law does not cover every North Dakotan

State employee insurance plans under the public employees retirement system are excluded from this law.

The Legislature will study prior authorization rules for those plans during the 2025-2026 interim session. The law also calls for a study on letting providers submit prior authorization requests electronically.

Insurers must now report annual data to the state insurance commissioner, including how many requests they approved, denied, and why.

Other states are moving in the same direction

North Dakota is not alone. At least 10 states passed prior authorization reform laws in 2024, and nine states plus Washington, D.C. did so in 2023.

Common changes include response deadlines, requirements for medically qualified reviewers, and protections for patients with chronic conditions.

In December 2025, the National Council of Insurance Legislators adopted a model prior authorization reform act, giving other states a ready-made template to follow.

Federal legislation targeting prior authorization in Medicare Advantage has also been introduced in Congress.

What the law means for patients starting now

North Dakota patients should no longer face open-ended waits for decisions on treatments their doctors have ordered.

If an insurer says no, a doctor with relevant experience made that call. Patients switching plans mid-treatment have a 60-day protection window.

The new annual reporting requirement will also show the public how often insurers approve or deny requests, adding a layer of accountability that did not exist before.

This article was created with AI assistance and human editing.

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