This document provides a summary of the North Dakota Department of Health
& Human Services’ Medicaid provider appeal process. It is not intended to be legal advice.
This information is subject to change.
1. Who Can Appeal?
A Medicaid provider can appeal a denial, reduction, recoupment, or adjustment decision by the North Dakota Department of Health & Human Services (Department). A “provider” means an individual, entity, or facility that furnishes medical or remedial services or supplies pursuant to a provider agreement with the Department or a third-party billing agency of the provider. (See North Dakota Century Code (N.D.C.C.) section 50-24.1-24(1)(b)).
2. What Can Be Appealed?
A denial, reduction, recoupment, or adjustment of payment by the Department can be appealed. The denial, reduction, recoupment, or adjustment in payment must be for a service provided to an individual who was eligible for Medicaid at the time the service was provided. A provider may not appeal the rate paid for a particular service. (See N.D.C.C. section 50-24.1-24(2)).
3. When Must An Appeal Be Filed?
A Medicaid provider must appeal within 30 days of the date of the Department’s notice of denial or reduction in level of service (remittance advice); or notice of recoupment or adjustment. (See N.D.C.C. section 50-24.1-24(2)).
4. How Is an Appeal Filed?
A Medicaid provider must file a written notice of appeal with the Department that includes a statement of each disputed item, the reason or basis for the dispute and must include the remittance advice or notice of recoupment or adjustment. (See N.D.C.C. section 50-24.1-24(2)). Provider appeals should be sent to:
Appeals Supervisor
ND Department of Health & Human Services
600 E. Boulevard Ave., Dept. 325
Bismarck, ND 58505-0250
Phone: (701) 328-2311
Fax: (701) 328-2173
Email: dhslau@nd.gov
Providers may use this form when submitting an appeal. ND Medicaid Provider Appeal Form (SFN 168).
5. What Happens After a Provider Files an Appeal?
Within 30 days of requesting an appeal, the provider must submit to the Department all documents, written statements, exhibits, and other written information that support the appeal. The provider must also provide a computation and the dollar amount of the provider’s claim for each disputed item. (See N.D.C.C. section 50-24.1-24(3)).
6. Who Will Review the Provider’s Appeal?
The Department will review the appeal and make a determination as to whether the provider’s claim has been substantiated and the claim should be paid as requested by the provider. The Department must assign the appeal to someone other than an employee who was involved in the initial denial of the claim. (See N.D.C.C. section 50-24.1-24(4)).
7. Can the Provider Talk to the Department About the Appeal?
Yes. A provider who has filed a timely appeal may contact the Department and request an informal conference regarding the appeal any time before the Department has issued its final decision. (See N.D.C.C. section 50-24.1-24(4)).
8. When Must the Department Issue a Decision?
The Department must issue its final decision within 75 days of receipt of the provider’s appeal for denial of payment or reduced payment for a service. The decision must explain the facts and authority that support the decision. (See N.D.C.C. section 50-24.1-24(5)).
The Department must issue its final decision within 75 days, or as soon thereafter as possible, of receipt of the provider’s appeal for recoupment or adjustment of a claim following an audit. The decision must explain the facts and authority that support the decision. (See N.D.C.C. section 50-24.1-24(5)).
9. What Rights Does the Provider Have After the Department Issues a Decision?
A provider may file an appeal with District Court, or they may file a petition request for reconsideration.
10. Provider May File An Appeal.
A provider can appeal the Department’s final decision to District Court. The District Court can review the Department’s final decision and the judgment of the District Court can be further appealed to the North Dakota Supreme Court. (See N.D.C.C. section 50-24.1-24(5)). There are certain deadlines that must be met in order to file an appeal with the District Court and the Supreme Court.
11. Provider May File A Petition For Reconsideration.
The Provider may file a written request for reconsideration with the Department within 15 days of the date of the final decision issued by the Department. The reconsideration request must be based on new evidence that was not available at the time of the appeal or show that the decision incorrectly interpreted the law. (See N.D.C.C. section 28-32-40; North Dakota Administrative Code (N.D.A.C.) section 75-01-03-25).
12. How to File a Petition For Reconsideration.
A Medicaid provider must file a written request for reconsideration with the Department that includes a description of the new evidence, an explanation as to why it was not available at the time of hearing, and its materiality; or information supporting how the decision incorrectly interpreted the law. Provider reconsideration requests should be sent to:
Appeals Supervisor
ND Department of Health & Human Services
600 E. Boulevard Ave., Dept. 325
Bismarck, ND 58505-0250
Phone: (701) 328-2311
Fax: (701) 328-2173
Email: dhslau@nd.gov
You do not give up your right to appeal this decision to District Court by requesting a reconsideration.
Updated: March 2023