ND Medicaid Provider Information



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Codes Requiring Service Authorizations
Electronic Data Interchange (EDI)/Electronic Claim Billing

For more information on electronic transactions (X12), visit our EDI webpage.

NDC to HCPCS Look-Up Tool
Online Forms

Group Authorization - Basic Care (PDF)

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 447 - Exemption for Submitting Electronic Claims
  • SFN 481 - Service Limits Service Authorization Request
  • SFN 511 - Medical Procedure/Device Service Authorization Request
  • SFN 527 - Genetic Testing Service Authorization Request
  • SFN 583 - Electronic Remittance Advice (835) Enrollment
  • 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 1059 - Authorization to Disclose Information
  • 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
Provider Appeals
Provider Newsletters

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Request Medicaid to add coverage for services, technology or procedure

You can request ND Medicaid to add coverage for noncovered services, technology, or procedures by filling out the SFN 905. Please answer all applicable questions. Include as much detail as possible. Submit completed forms along with any additional supporting documentation to dhsmed@nd.gov

Web File Transfer System

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.

Registered Users

Login Now >

Registration Process

Please complete the following steps (Note: You only need to complete these steps once.)

Step 1Sign up for North Dakota Login ID

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.


Additional Information and Resources

Medicaid Contacts

Medicaid Contacts

Medical Services Division
North Dakota Health and Human Services 
600 E. Boulevard Ave., Dept. 325
Bismarck, ND 58505-0250

Email: dhsmed@nd.gov
Phone: (701) 328-7068
Toll-Free: (800) 755-2604
Fax: (701) 328-1544
711 (TTY)

Medical Services Call Center

Phone: (701) 328-7098
Toll-Free: (877) 328-7098
Email: mmisinfo@nd.gov