- Coordinated Services Program - Updated April 2026
- Covered Services
- Electronic Visit Verification
- Noncovered Services
- Ordering/Referring/Prescribing Providers
- Other Licensed Providers (OLP)
- Provider Appeal
- Provider Enrollment
- Provider Requirements
- Recipient Liability
- Sign and Oral Language Interpreter Services
- Telehealth
- 1915(i) Medicaid State Plan Amendment
- Autism Applied Behavior Analysis Service
- Behavioral Health Rehabilitative Services - Updated March 2026
- Institutions for Mental Disease (IMD) Policy - Updated May 2026
- Partial Hospitalization Psychiatric (PHP) Services - Updated April 2026
- Psychiatric Residential Treatment Facilities (PRTF)
- Qualified Residential Treatment Programs (QRTP)
- Substance Use Disorder Treatment and Housing Providers
- Substance Use Disorder Treatment Services - Updated April 2026
Claims Guidance
Crossover Claims
Electronic Claims Submission - Dental Claims
Electronic Claims Submission - Medical Claims
Electronic Funds Transfer
Exemption for Submitting Electronic Claims - SFN 447
Member Eligibility
Direct Secure Messaging (DSM) Instructions for Third Party Billers
Third Party Liability (TPL)
Third Party Biller
Timely Claims Filing
Timely Claims Filing Override Request
- Dental Case Management
- Dental Procedures and Nomenclature
- Dental Provider Training Video - Common Errors - (Total Running Time 39 minutes) April 2022
- Dental Provider Video Training (Total running time 1:05)
- Dental Screening and Assessment
- Dental Training Materials
- Facility Calls
- North Dakota Dental Periodicity Schedule
- Orthodontics
- Place of Service Codes
- Teledentistry
- Tooth Numbering System
- Durable Medical Provider Information
- Durable Medical Equipment(DME) Reuse Policy
Federally Qualified Healthcare Centers (FQHC)
Indian Health Service and Tribal Health Programs
Rural Health Clinics (RHC)
- Ambulatory Surgery Center Services
- Basic Care Facilities - Updated April 2026
- Hospital Service - Updated April 2026
- Intermediate Care Facilities (ICF/IID)
- Nursing Facilities - Updated April 2026
- Nursing Facilities - Rate Setting Manual
- Nursing Facilities - MDS 3.0 Submission Guidelines
- Nursing Facilities - MDS Appeal Request Form (SFN 247)
- Nursing Facilities - ND Payment System Booklet (January 2012)
- Nursing Facilities - Maximus PASRR/Level of Care manual and forms
- Swing Bed Facilities - Updated April 2026
Abortion
Ambulance Services
Anesthesia Services
Breast and Cervical Cancer Detection
Cardiac Rehabilitation
Chiropractic Services
Clinical Trials
Community Health Worker
Community Paramedicine
Family Planning Services
Forensic Examinations
Gender Affirming Care
Home Health - Updated April 2026
Hospice Services
Immunizations
Laboratory and Pathology Services
Local Public Health Units (LPHU)
Medication for Opioid Use Disorder (MOUD)
Non-Emergency Medical Transportation
Non-Emergency Medical Transportation - Documentation Guidelines
Non-Emergency Medical Transportation - Toolkit
Occupational Therapy - Updated April 2026
Optometric and Eyeglass Services
Physical Therapy - Updated April 2026
Physician Administered Drugs - Updated April 2026
Professional Medical and Surgical Services - Updated April 2026
Preventive Services and Chronic Disease Management and EPSDT Services
Private Duty Nursing Services - Updated April 2026
School-Based Services
Speech Language Services - Updated April 2026
Sterilization and Hysterectomy
Transplant Services - Updated April 2026
Pharmacy Provider Manual
Out of State Services
Service Authorizations
Child Welfare
Child Welfare - Training Slides
High-Risk Pregnant Women
TCM for Behavioral Health
Purpose
This policy contains general information about services covered by Medicaid.
Applicability
Eligible Providers
To receive payment from ND Medicaid, the eligible servicing and billing providers' National Provider Identifier (NPI) must be enrolled on the date of service with ND Medicaid. Servicing providers acting as a locum tenens provider must enroll 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.
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 Automated Voice Response System by dialing 1.877.328.7098.
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 ordering/referring/prescribing requirements, Service Authorization requirements, and current rates.
Covered services are subject to change based on changes in funding, legislative action, and changes in administrative rules.
| Service | Limits | Service Authorization Required | Age Restrictions |
|---|---|---|---|
| 1915(i) Services | Yes | Yes, see 1915(i) chapter | Yes |
| Ambulance services | No | For emergency out of state transport: referring providers have 48 hours following the service to notify ND Medicaid of transport. | No |
| Ambulatory surgical services | No | Some services require a service authorization (SA) from Acentra Health. | No |
| Audiology | No | No | No |
| Autism Spectrum Disorder Applied Behavioral Analysis Service | No. Services must be included in the plan of care. | Yes, annually, and a 180-day update. | Yes, must be under 21 years of age. |
| Behavioral health services | No | No | No |
| Certified nurse midwife services | No | No | No |
| Chiropractic services | 20 manipulations per year; x rays 2 per year | Yes, after limits are met. | No |
| Dental services | Some limits apply - see Dental manual | Some services require SA – see Dental manual. | Some age restrictions apply. See Dental manual. |
| Durable medical equipment, medical supplies, prosthetic providers, hearing aids | Some limits apply - see DME manual | Some services require SA - see DME manual | Some age restrictions apply. See DME manual |
| Emergency Services, and follow-up care | No | No | No |
| Family planning | No | No | No |
| Federally qualified health centers (FQHC) | No | No | No |
| Health Tracks (EPSDT) Screening | No | No | Yes, through age 20. |
| Home and community-based services (HCBS waiver) | No | Must be screened and meet level of care. | No |
| Home health care services | 50 visits per year | Yes, after limit is met. | No |
| Hospice | Some limits apply | Hospice election and certification required. | No |
| Hospitals (inpatient) | rehab limited to 30 days per stay for adults | Some in-state services require SA. All out of state admissions require SA. | No |
| Hospital swing bed services | No | Yes, must meet level of care | No |
| Immunizations | No | No | Yes, some age restrictions apply |
| Inpatient psychiatric services | Yes | Yes, must meet certificate of need if under age 21. | Yes, services provided in an IMD to members 21 through 64 are noncovered |
| Intermediate care facilities for individuals with intellectual disabilities | No | Yes, must meet level of care. | No |
| Laboratory | No | Some services require a SA. | No |
| Local Public Health Units | No | No | No |
| Medical Nutritional Therapy | Yes, 4 hours per year | Yes, after limit is met. | No |
| Medication Therapy Management | Some limits apply. See ND Medicaid Medication Therapy Manual | Service Authorization recommended. See ND Medicaid Medication Therapy Manual. | No |
| Nonemergency medical transportation | No | Yes, administered by human service zones. | No |
| Nurse practitioner services | No | No | No |
| Nursing facility services | No | Yes, must meet level of care. | No |
| Occupational therapy | 30 visits per year for ages 21 and over | Yes, after limit is met. | No |
| Optometric services | Some limits apply – see Optometric and Eyeglass Services chapter | Some services require SA – see Optometric and Eyeglass Services chapter. | No |
| Orthodontia | No | Yes, must be referred by Health Tracks | Yes, through age 20. |
| Partial hospitalization program | No | No | No |
| Partial hospitalization program | No | No | No |
| Personal care services in a member’s home | Service limits apply | Yes | No |
| Pharmacy | Some limits apply - see pharmacy manual | Some services require SA - see pharmacy manual. | No |
| Physical therapy | 30 visits per year for ages 21 and over | Yes, after limit is met. | No |
| Physician services, Primary Care | No | No | No |
| Physician Services, Specialty Care | Limits apply to some specialist services. | Some services require an SA. | No |
| Podiatry | No | No | No |
| Private duty nursing | Yes | Yes | No |
| Psychiatric Residential Treatment facilities (PRTF) | No | Yes, must meet certificate of need. | Under 21 only |
| Radiology | No | No | No |
| Behavioral Health Rehabilitative Services | Some limits apply. See Behavioral Health Services Manual | Some services require SA. See Behavioral Health Rehab Services. | Some services are restricted to certain ages. See Behavioral Health Services Manual |
| Rural health clinics (RHC) | No | No | No |
| School-based Services (Individualized Education Plans (IEPS) & Non-IEPs) | No | Some services require SA. See School Based Services. | Under 21 only |
| Speech therapy | 30 visits per year for ages 21 and over | Yes, after limit is met. | No |
| Substance Use Disorder Treatment Services | No | No | No |
| Targeted case management | No | No | Yes, for child welfare and behavioral health. |
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
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.
References
Related Policies
Contact
Medical Services
600 East Boulevard Ave Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov
Policy Updates
October 2025
| Section | Summary |
|---|---|
| Covered Services and Limits | Removed the entire column titled Referral Required from Primary Care Provider due to the PCCM Program ending December 2023. Replaced ‘serious mental illness, severe emotional disturbance’ with behavioral health in the Targeted Case Management row. |
| Covered Services and Limits | Format changes and clarifications added throughout. |