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- ADA 2006/2012 Paper Claim Form Billing Instructions (October 2015)
- QSP Paper Claim Form Billing Instructions (Aug. 2015)
- UB-04 Paper Claim Form Billing Instructions (October 2015)
- CMS-1500 Paper Claim Form Billing Instructions (October 2015)
- Travel and Lodging Paper Claim Form Billing Instruction (Updated Aug. 2016)
See the Medicaid Coverage Guidelines for additional information.
CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
The Medicaid coding guideline files for all physicians are presented in PDF format. To receive the information in an alternative format, contact firstname.lastname@example.org.
Table of Contents
- Chiropractic Services (Revised 10/1/2016)
- Developmental Screenings and Brief Behavioral Assessments (Revised 9/2022)
- Encounters for Routine and Administrative Services (Revised 9/2021)
- Fluoride Varnish (Effective 1/1/2023)
- HIV screenings (Created 4/2020)
- Maternal Depression Screening (Revised 10/2022)
- Medical Nutrition Therapy (Revised 6/2020)
- Synagis (Palivizumab) (Revised 9/2022)
- Vaccine/Toxoids (Revised 2/2022)
For technical assistance please contact email@example.com or 860-563-1223
Additional Information and Resources
All forms listed below are fillable.
- SFN 15 - Home Health Request for Service Authorization
- SFN 177 - MMIS Attachment Cover Sheet
- SFN 292 - Request for Service Authorization for Vision Services
- SFN 308 - Medicaid and Basic Care Assistance Programs Provider Agreement
- SFN 481 - Service Limits Service Authorization Request
- SFN 511 - Medical Procedure/Device Service Authorization Request
- SFN 527 - Genetic Testing Service Authorization Request
- SFN 606 - Medicaid Out of State Services Certification
- SFN 614 - Physician Certification for Sterilization and Recipient Acknowledgement of Sterility
- SFN 615 - Medicaid Program Provider Agreement
- SFN 661 - Electronic Funds Transfer (EFT) Form
- SFN 662 - Personal Care Services Plan
- SFN 663 - Personal Care - Authorization to Provide Personal Care Services
- SFN 705 - Health Tracks Appointment Slip
- SFN 710 - Health Tracks Referral and Request for Information
- SFN 769 - Request for Service Authorization for Out-of-State Services
- SFN 871 - ND Health Tracks Screening Results
- SFN 905 - Technology/Procedure Assessment
- HHS-687 - Consent for Sterilization (required federal form)
- SFN 1105 - Medication Therapy Management (MTM) Provider Enrollment Application
- SFN 1106 - Medication Therapy Management (MTM) Service Authorization Request
- SFN 1110 - Medication Therapy Management (MTM) Missed Appointment
- SFN 1168 - Ownership/Controlling Interest and Conviction Information
- SFN 1169 - Pharmacy Agreement/Medical Assistance Program
Medical Policy (53kb pdf)
Dental Policy (34kb pdf)
Learn how to submit claims electronically:
If you have trouble viewing the e-newsletters below, cut and paste the URL into another web browser – Chrome, Firefox or Internet Explorer or Safari for Mac users.
- December 2022 (e-newsletter) PDF of newsletter (1.5mb pdf)
- September 2022 (e-newsletter) PDF of newsletter (179kb pdf)
- June 2022 (e-newsletter) | PDF of newsletter (1.18mb pdf)
- March 2022 (e-newsletter) PDF of newsletter (330kb pdf)
- December 2021 (e-newsletter) PDF of newsletter (1.14mb pdf)
- September 2021 (e-newsletter) PDF of newsletter (705kb pdf)
- June 2021 (e-newsletter) PDF of newsletter (1.46mb pdf)
- March 2021 (e-newsletter) PDF of newsletter (1mb pdf)
- December 2020 (e-newsletter) PDF of newsletter (1.20mb pdf)
- September 2020 (e-newsletter) PDF of newsletter (2.16mb pdf)
- June 2020 (e-newsletter) PDF of newsletter (9.87mb pdf)
- December 2019 (e-newsletter) PDF of newsletter (7mb pdf)
- September 2019 (e-newsletter) PDF of newsletter (9.54mb pdf)
- June 2019 - Issue 78 (528kb pdf)
- March 2019 - Issue 77 (421kb pdf)
Web File Transfer System
This system accepts files for all Medicaid payments via a secure environment.
You will need to be a registered user of the Medical Services Web File Transfer. To register, you must obtain a State of North Dakota Login ID and Authorization Code.
Please complete the following steps (Note: You only need to complete these steps once.)
Step 2. After you have created your Login ID and Password (by signing in above), you will receive an e-mail directing you to confirm your password. After confirming your password, Login to the Web File Transfer System.
Step 3. Request Authorization Code from Web File Transfer System page. (Please allow up to 20 days for the Authorization Code to be mailed to you.)
Step 4. To complete your registration, you will be asked to login with your State of North Dakota Login ID. Then you will be asked to enter the Authorization Code you received in the mail. After completing this step, you are now registered for on-line access to the Medical Services Web File Transfer.
If you have questions please check the Frequently Asked Questions page.