ND Medicaid Provider Newsletter - December 2025

Community Health Workers and Community Paramedicine coverage

Upcoming updates to Chiropractic Services Policy

North Dakota Medicaid is updating the Chiropractic Services policy and changes may impact your members. These changes will take effect for dates of service on or after Jan. 1, 2026 and are critical for ensuring continued compliance and proper reimbursement for chiropractic services.

Key policy updates

Modifier -AT Requirement

• The -AT modifier must now be appended to all Chiropractic Manipulative Treatment (CMT) codes (98940–98942) to indicate active/corrective treatment for acute or chronic subluxation.
• Claims submitted without this modifier will be denied as non-covered

Diagnosis Reporting – Subluxation Level

• The level of subluxation must be listed as the primary diagnosis on the claim using the ABK qualifier.
• This requirement is essential to support the medical necessity of the CMT service.

New Documentation Requirements

• Specific documentation standards have been added for both initial and subsequent chiropractic visits.
• Providers must now include:
• Detailed patient history
• Physical examination findings
• Diagnosis
• Treatment plans
• Progress assessments
• Proper documentation is critical for justifying billed services and maintaining compliance with Medicaid requirements.

Provider action

We strongly encourage all providers to review the updated Chiropractic Services Policy in detail to ensure full understanding and implementation of these changes. Adhering to these requirements will help avoid claim denials and ensure smooth reimbursement processes.

Tax update for all Medicaid providers

North Dakota Health and Human Services mails 1099s to the billing address listed in the MMIS portal. To update the address information in MMIS, the following forms must be completed:

Provider Enrollment Coversheet
SFN 1299 - Group Address Update

Submit the completed forms to Noridian at NDMedicaidEnrollment@Noridian.com.

Your prompt attention to this matter is appreciated.

Medicaid Member Engagement Committee (MMEC) open seats

Click on flyer to download.

ND Medicaid Quality Team update

North Dakota Medicaid is  participating in the Centers for Medicare and Medicaid Services (CMS) Early Childhood Preventative Care Affinity Group. We are excited to collaborate with other states in improving well-child care and sharing best practices. 

Work started in October 2025 and will wrap up in 2027. By participating in this group, North Dakota Medicaid will focus on  children 0-30 months who have not received their recommended well-child visits. We encourage providers to schedule  patients’ next appointments before they leave their current visit to help them stay on schedule and healthy.

Help us help ND children stay healthy with fluoride varnish

Let’s ensure Medicaid-eligible youth are receiving fluoride varnish, a preventive service, by offering it at all well-child visits. Thank you to our clinical providers who have already integrated fluoride varnish applications into their well-child visits.     

Access to dental services is an ongoing and statewide challenge for our Medicaid members. Dental caries remains the most common chronic preventable childhood disease in the United States. Having untreated dental caries can impact a child’s physical health, nutrition and can lead to missed school. The use of fluoride varnish is an effective way to prevent and, in some cases, stop dental decay.  

A review of our claims data (paid and denied) for fluoride varnish application during calendar year 2024 and Jan. 1 through June 30, 2025 shows the number of fluoride varnish applications in comparison to EPSDT well-child visits billed by:

• Private medical setting (Procedure codes S0302 or 9938x / 9939x)
• Local Public Health Units (Procedure code S0302)
• Rural Health Clinic Revenue Code 0521 + (Procedure codes S0302 or 9938x / 9939x)
• Federally Qualified Health Center Revenue Code 0521 +(Procedure codes S0302 or 9938x / 9939x)
• IHS Revenue Code 0500* or 0519 + (Procedure codes S0302 or 9938x / 9939x)
  *Due to upcoming NDMA system changes in 2026, the 0500 Revenue Code with the 99x codes will be denied and sent back to be corrected. Training will be provided.

Our review showed that there were 65,499 EPSDT well-child visits and of those only 11,929 offered fluoride varnish with the well-child visit. Missed opportunities are where fluoride varnish could have been applied as part of a well-child visits, which also results in missed reimbursement.

These missed opportunities are a detriment to our members to receive a protective service, which is especially important due to the limited dental access in our state.   

Fluoride varnish continues to be a requirement of well-child visits and is one of the CMS core measurements. 

Medicaid is encouraging medical providers to integrate fluoride varnish applications into well-child visits. The Fluoride Varnish CPT© code for medical providers is 99188.  Fluoride varnish may be applied 2x/year by medical providers for children and 3x/yr by dental providers. The Fluoride Varnish CPT© code for dental providers is D1206. Check out the Wellness Visit Provider Toolkit for information on oral health, fluoride varnish and orthodontia.

If you would like to know the specific number of missed opportunities for your provider setting or you are interested in learning how your providers can begin to integrate fluoride varnish into your well-child visits, email qualityprovideroutreach@nd.gov.     

To find a dentist who accepts Medicaid, visit InsureKidsNow.gov.

Learn more at About Wellness Visits.

Pharmacy updates

Stay informed of recent and upcoming drug coverage changes to support continuity of care and avoid prescription delays. Current coverage criteria are outlined in the Preferred Drug List (PDL).

Effective Dec. 1, 2025: Electronic age verification applies to Arnuity Ellipta claims to ensure use of approved dosing that aligns with current asthma guidelines.

Electronic age verification occurs during adjudication at the point of sale.

• Arnuity Ellipta 100 mcg and 200 mcg strengths: Member must be age 12 years or older.
• Arnuity Ellipta 50 mcg strength: Member must be age five years through 11 years.

Effective Oct. 1, 2025: Dulera is the only preferred inhaled corticosteroid/long-acting beta agonist (ICS/LABA) inhaler that does not require prior authorization (PA).

• Advair HFA and Advair Diskus are non-preferred status and require PA.
• All other ICS/LABA inhalers remain non-preferred status and require PA.

Dulera contains formoterol and can be used for single-inhaler maintenance-and-reliever therapy (SMART) as recommended in asthma guidelines. ND Medicaid allows up to two Dulera inhalers per 30-day supply for SMART use.

Effective Oct. 1, 2025: Steqeyma no longer requires PA.

• Selarsdi and Yesintek remain Step 1 non-preferred status and require PA.
• Stelara and other ustekinumab biosimilars remain Step 2 non-preferred status and require PA.

Effective October 1, 2025: Ozempic and Rybelsus are preferred status and do not require PA.

• Liraglutide (generic Victoza) will be non-preferred status and require PA.
• Victoza (brand) will remain preferred status but is experiencing market availability issues.
• Trulicity remains non-preferred status and requires PA.

Effective Oct. 1, 2025: The manufacturer of Xifaxan and Trulance ceased participation in the Medicaid Drug Rebate Program (MDRP).

• Xifaxan and Trulance are no longer eligible for coverage by ND Medicaid.
• Medicaid members may apply to the manufacturer’s patient assistance program (PAP) to obtain Xifaxan or Trulance (https://www.bauschhealthpap.com/).

ND Medicaid is not able to pay for a drug when the manufacturer does not participate in the MDRP due to federal law, Sec.1927. [42. U.S.C. 1396r-8] (a).

• Manufacturers choose whether they will sign up for the MDRP.
• Manufacturer participation is outside of ND Medicaid’s control.
• An alternative, participating manufacturer’s product or different drug that is covered must be used for Medicaid to be able to pay.

Effective Oct. 1, 2025: Methylphenidate 10 mg/5 mL solution is the only preferred non-solid dosage formulation of methylphenidate immediate release (IR).

• PA is not required for ages six through nine years.
• Electronic age verification occurs during adjudication at the point of sale.

Effective Oct. 1, 2025: Clonidine patches require PA for members 10 years and older.

• Electronic age verification occurs during adjudication at the point of sale.
• See the Non-Solid Dosage Forms criteria in the PDL.

Effective Oct. 1, 2025: J0248 (Veklury) requires PA. Paxlovid is the preferred antiviral for COVID-19 and does not require PA.

Effective Sept. 30, 2025: J1745 (Remicade** or infliximab) no longer requires PA.

• **Brand Remicade does not require PA, but generic infliximab should be used as an alternative to brand Remicade for adequate reimbursement.
• See the Preferred Drug List for preferred biosimilars.

Claims Corner 

North Dakota Medicaid will require Federally Qualified Health Centers dental services to be submitted on the American Dental Association claim form (837D) with dates of service on or after Jan. 1, 2026. For dates of service before Jan. 1, 2026, claims must be submitted on the UB-04 (837I).

Providers can utilize the Procedure Code Look-up Tool to verify which dental services are covered.

When billing dental procedures that require a service authorization, the service authorization number must be submitted on the claim.

For questions, reach out to Alyssa Neis, aneis@nd.gov.