Coordinated Service Provider (CSP)

Purpose

ND Medicaid uses the CSP to:

• Improve the continuity and quality of medical care for members;
• Improve utilization patterns to control Medicaid expenditures; and
• Provide education on the utilization of services at the appropriate level.

Applicability

Eligible Providers

To receive payment from ND Medicaid, the eligible servicing and billing provider National Provider Identifiers (NPI) must be enrolled with ND Medicaid on the date of service. Servicing providers acting as a locum tenens provider must be enrolled with ND Medicaid and be listed on the claim form. Please refer to provider enrollment for additional details on enrollment eligibility and supporting documentation requirements.

CSP services can be provided by the following enrolled providers as allowed by their scope of their licensure:

• Physician,
• Physician’s Assistant; or
• Nurse Practitioner.

Eligible Members

Providers are responsible for verifying a member’s eligibility before providing services. Eligibility can be verified using the ND Medicaid MMIS Portal or through the through the Automated Voice Response System by dialing 1.877.328.7098.

ND Medicaid uses parameters to determine if a member may be referred to CSP. These parameters include:

• Use of multiple providers and clinics;
• Early prescription refills and use of multiple pharmacy providers;
• Use of emergency room for services other than emergent care; and/or
• Prescription use that is excessive or potentially threatening to the health of the member indicated by:
  • Multiple prescribing providers;
  • Use of multiple controlled drugs; or
  • Overlapping prescriptions with counterproductive therapeutic value.

Refer to the Member Eligibility Manual for additional information regarding eligibility including information regarding limited coverage categories.

Covered Services and Limits

General Provider Policies

The General Provider Policies details basic coverage requirements for all services. Basic coverage requirements include:

• The provider must be enrolled in ND Medicaid;
• Services must be medically necessary;
• The member must be eligible on the date of service; and
• If applicable, the service has an approved service authorization.

The Procedure Code Look-up Tool can be used to identify if a procedure code is covered by ND Medicaid along with code specific details such as ORP requirements, Service Authorization requirements, and current rates.

Program Requirements

Members that are referred to the CSP must choose a coordinated services provider by selecting a physician, nurse practitioner, or physician assistant with a specialty of family practice, general practice, or internal medicine. CSP members are also required to select one pharmacy of their choice to manage their prescription needs. The member may also be required to select one dentist of their choice based on the usage of dental services.

The member's selection of a CSP provider is subject to approval by ND Medicaid.

The requirement for coordinated services is made by ND Medicaid upon recommendation of medical professionals who identify utilization patterns indicating the member may benefit from the CSP.

A review of services may be initiated by:

• A member audit of medical and pharmacy services;
• A recommendation from a medical professional; or
• ND Medicaid staff.

Medical professionals may make recommendations for immediate placement of members into the CSP; however, the final decision remains with the fraud and abuse administrator and utilization review unit.

Pharmacy Transactions

See the Pharmacy Provider Manual for more information about CSP members and pharmacy transactions. More information is available on the ND Medicaid Pharmacy Providers webpage.

Services Obtained from a Non-Designated Provider

ND Medicaid will not pay for medical care or services furnished to a CSP member by any provider other than the member's CSP provider, except for:

Medical care rendered in a medical emergency; or

Medical care rendered upon CSP provider referral and approval by ND Medicaid.

Treatment by a Specialist

Only the member's CSP provider can authorize a referral to a specialist using the CSP Referral Form (SFN 231) or calling CSP at 1-800-755-2604 or 701-328-2346. Referrals must be medically necessary and sent to ND Medicaid prior to the date of service. ND Medicaid will not approve retroactive referrals. Once authorized by ND Medicaid, the specialist may order tests and treatment. If additional specialists are needed, the CSP provider must initiate the referral.

If a CSP provider is going to be absent from practice for an extended period of time, the CSP provider should refer the member to another provider to access necessary medical services. This information must be communicated to ND Medicaid prior to a member receiving services.

A CSP provider may use their own referral form if the form contains the name and NPI of the CSP provider, the name and ND Medicaid ID number of the member being referred, the name and NPI of the provider to whom the member is being referred, the duration of the referral, and a dated signature of the CSP provider.

Services Obtained in the Emergency Department or Urgent Care Clinic

Services obtained in the Emergency Department or Urgent Care Clinic require documentation to be sent with each claim.

Service Authorization Requirements

No service authorization required.

Non-Covered Services

General Non-Covered Services

The Noncovered Services Policy contains a general list of services that are not covered by North Dakota Medicaid.

Documentation Requirements

General Requirements

Providers must keep legible medical and financial records that fully justify and disclose the extent of services provided and billed to ND Medicaid. Records must be retained for at least 7 years after the last date the claim was paid or denied. Providers must follow the documentation requirements in the Provider Requirements Policy.

Reimbursement Methodology and Claim Instructions

Timely Filing

ND Medicaid must receive an original Medicaid primary claim within one hundred eighty (180) days from the date of service. The time limit may be waived or extended by ND Medicaid in certain circumstances. The Timely Filing Policy contains additional information.

Third-Party Liability

Medicaid members may have one or more additional source of coverage for health services. ND Medicaid is generally the payer of last resort. Providers must pursue the availability of third-party payment sources. The Third Party Liability Policy contains additional information.

Client Share (Recipient Liability)

Client share (recipient liability) is the monthly amount a member must pay toward the cost of medical services before the Medicaid program will pay for services received. The Client Share Policy contains additional information.

Reimbursement

A claim for services must be submitted at the provider’s usual and customary charge. Payment for services is limited to the lesser of the provider’s usual and customary charge or the ND Medicaid calculated reimbursement.

Claim Form

Professional services must be billed using the CMS-1500 claim form or the 837p HIPPA compliant X12 format. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.

Facility services must be billed using the UB-04 claim form or the 837i HIPPA compliant X12 format. Detailed claims instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.

Claim Requirements

For any services done outside of the CSP office a referral is required prior to services being rendered.

References

• North Dakota Administrative Code
• North Dakota Century Code
• Code of Federal Regulations

Contact

Medical Services
600 East Boulevard Ave Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov

Policy Updates

April 2026

Clarifications and format changes throughout the policy.