ND Medicaid Provider Newsletter - March 2026

Behavioral health rehabilitative services policy update

In January 2026, ND Medicaid implemented soft service limitations on certain services in the Behavioral Health Rehabilitative Services policy. To ensure that providers are successful in submitting service authorizations for medically necessary services, further additions have been made to the policy, clarifying documentation standards. We hosted a webinar in February to review these documentation standards. If you would like to receive the recording of this webinar, reach out to policyfeedback@nd.gov.

2026 adjustment process changes for post-payment review of professional emergency department claims

Effective April 1, 2026, there will be a change to the adjustment process for professional Emergency Department (ED) claims identified by Acentra as incorrectly coded during post-payment review. This updated process is designed to streamline adjustments and reduce the administrative burden on providers and ND Medicaid.  

What is changing

Each quarter, starting April 1, 2026, ND Medicaid will:

  • Send a recovery letter to providers that contains all professional ED claims identified by Acentra as being incorrectly coded. Providers will have 30 days from the date of the recovery letter to file an appeal for each claim related to the audit findings.    
  • If no appeal is received by the department within 30 days, the department will: 
    • Create an adjustment of the claim(s) identified by the audit, 
    • Replace the incorrect CPT® code with the appropriate CPT® code based on the documentation reviewed by Acentra (no other claims information will be altered), and  
    • Append modifier CC – procedure code change, to the claim line being changed (modifier CC would be added after any payment modifiers listed on the original claim line, i.e., modifier 25).

What providers should expect

  • Modified CPT® codes and modifiers on their remittance advice.
  • Decreased administrative burden due to ND Medicaid initiating claim adjustments and code changes.
  • Decreased turnaround time between recoupment and repayment of claims identified by Acentra.

Provider responsibilities

Ensure coding and billing staff are aware of the updated adjustment process, effective April 2026.  

  • Avoid self-adjusting claims related to the professional ED claim audit being performed by Acentra.

Questions or assistance

For questions regarding this update, please contact the Program Integrity Unit compliance coordinator at PIUCC@nd.gov.

1915(i) billing update

The 1915(i) program is designed to help individuals in their homes and their community of choice, by providing home and community-based services where the member is at in their life. The first step in 1915(i) program is getting a member established with a care coordinator. The care coordinator takes a holistic view of all of the member’s needs and wants. From this, the care coordinator and the member together will create a person-centered plan of care. The plan of care will be the roadmap the care coordinator uses to connect the member with services of their choice. Once services are established, the care coordinator will continuously monitor the members’ services, constantly working to make sure the member is receiving the support they need.

To further help lower the administrative lift for 1915(i) providers, starting on Jan. 1, 2026, all billing for 1915(i) will be generated and submitted though Therap. This transition is a key component in the state’s continued effort to help 1915(i) service providers spend less time on administrative tasks, and more time working with those in need. Please visit the 1915(i) webpage for more details on this and the many exciting parts of 1915(i).

Chiropractic claims reminder

As of Jan. 1, 2026, billing requirements for chiropractic claims have changed. Two ICD-10-CM codes must be listed on the claim or service authorization to support the medical necessity of CMT.

  • The level of subluxation must be specified and must be listed as the primary diagnosis (ABK qualifier) on the claim.
  • The associated neurological or musculoskeletal disease or symptom that is a direct result of the subluxation necessitating treatment must be listed as the secondary diagnosis (ABF qualifier).
  • Modifier -AT must be appended to all CMT codes for active/corrective treatment to treat acute or chronic subluxation. CMT codes without a modifier -AT will be denied as non-covered.
  • Both the primary and secondary diagnosis codes must be listed on the line level of the claim.

Billing changes to the ND Ryan White program

As of Jan. 1, 2026, the ND Ryan White Program transitioned to a direct billing process for outpatient/ambulatory medical care (OAMC) claims through the ND Medicaid Management Information System (MMIS). To submit medical claims, please follow the ND Medicaid claims guidance and use the member ID listed on the client’s OAMC card.

A list of covered services, once available, will be accessible at the North Dakota Ryan White Program webpage. The Ryan White Program serves as a payer of last resort, and Medicaid, Medicare, or private insurance must be billed first.  

Pharmacy claims can continue to be submitted using the BIN of 601364, PCN of DRNDPROD, and ADAP Group ID of NDMEDIRYNWHT. This information is listed on the member’s card. 

For questions regarding client eligibility, claims billing or covered services, contact the Ryan White Program at (701) 328-2378 or oamc@nd.gov.

Updates from the Quality Outreach team

In September, we announced that the Health Tracks team is now the Quality Outreach team. This new name better reflects the work we do.

To support both members and providers through a unified approach, we’ve also consolidated our contact information:

While the name Health Tracks focused on children’s preventive services (Early, Periodic, Screening Diagnostic and Treatment or EPSDT), our mission has grown to support quality and health goals across the entire Medicaid population. The new name also helps avoid confusion, as many associated Health Tracks with a stand-alone Medicaid program. Quality Outreach Team better reflects our team’s dedication to advancing health and quality outcomes for our entire population across North Dakota Medicaid.

In order to advance health outcomes, it is important for providers to encourage wellness visits.

These visits are important for all children, including those with special health care needs and under the care of specialists. We encourage providers to schedule follow-up visits with families prior to them leaving your clinic.

What’s included in EPSDT wellness visit?

  • Physical exam
  • Hearing check
  • Dental screening and fluoride varnish 
  • Orthodontic screening (for participating providers) 
  • Vision screening 
  • Lab tests, including lead screening 
  • Immunizations 
  • Developmental/Mental health screenings 
  • Other health services

What’s included in an adult wellness visit?

  • Cancer screenings (age-appropriate)
  • Management of chronic conditions
  • Health promotion (nutrition, exercise, lifestyle, smoking cessation)
  • Reproductive health counseling and screenings
  • Pregnancy & postpartum care
  • Well-women care

To learn more about the EPSDT wellness visit benefits, visit our wellness visits for providers webpage.

If you have patients who need assistance getting to and from your clinic or have other eligibility questions, call (866) 614-6005 or email applyforhelp@nd.gov.

Join the Medicaid Medical Advisory Committee (MMAC)

ND Medicaid is accepting applications for open seats on the MMAC. The MMAC brings together health care and social service providers, members and their families and other partners to review existing and new Medicaid policies and changes and provide and receive updates on key Medicaid activities.

To apply, fill out this application.

CMS approves most of North Dakota's year-one Rural Health Transformation (RHTP) budget

Thank you for your interest in North Dakota’s Rural Health Transformation Program (RHTP), a five-year investment to strengthen rural health care and help make North Dakota the healthiest state in the nation.

On Feb. 25, 2026, the Centers for Medicare and Medicaid Services (CMS) approved $194,807,869.55 for North Dakota’s year-one RHTP budget. The remaining $4,129,100 is still under review with CMS. This was a required step that aligned CMS’s Notice of Award amount with the budget request North Dakota submitted as part of its RHTP application in early November 2025.

This approval allows North Dakota Health and Human Services (ND HHS) to move forward with program implementation and begin releasing funding opportunities in phases.

Funding Information
We have a short window to put the first year of funding to work. ND HHS is prioritizing funding opportunities that build on existing infrastructure, partnerships and systems already in place, so we can move quickly and maximize impact.

The year-one funding must be obligated by Oct. 30, 2026, and fully spent by Sept. 30, 2027.

ND HHS expects to release one of the first funding opportunities to support the retention of rural and tribal providers as soon as possible. We anticipate this to be announced in early to mid-March. Additional opportunities will follow in the coming weeks and months.

All funding opportunities will be posted on the Rural Health Transformation Program webpage as they become available. You are encouraged to check this webpage often for updates and other important information.

The RHTP is supported by CMS of the U.S. Department of Health and Human Services (US HHS) as part of a financial assistance award totaling $198,936,969.55 with 100% funded by CMS/US HHS. The contents are those of ND HHS and do not necessarily represent the official views of, nor an endorsement by, CMS/US HHS, or the U.S. Government.

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 immediately for estrogen patches:

  • Climara is now preferred and does not require PA. 
    • Menostar is no longer preferred and requires PA.
    • Generic weekly estradiol patch is no longer preferred and requires PA.
  • Minivelle is no longer preferred and requires PA.
    • Vivelle-Dot remains preferred and does not require PA.
    • Generic twice weekly estradiol patch remains non-preferred and requires PA.
    • Dotti remains non-preferred and requires PA.
    • Lyllana remains non-preferred and requires PA.

Effective immediately for triptans (nasal spray and injectable):

  • Sumatriptan nasal spray is no longer preferred and requires PA.
  • Zolmitriptan nasal spray is now preferred and requires PA.
  • Sumatriptan vial now requires PA.

Effective immediately for interferons:

  • Rebif is no longer preferred and requires PA.
  • Betaseron is no longer preferred and requires PA.
  • Avonex remains preferred and does not require PA.

Effective immediately for Movantik:

  • Movantik is no longer preferred and requires PA.
  • Lubiprostone and Symproic remain preferred and do not require PA.

Effective immediately for formoterol:

  • Formoterol is no longer a preferred long-acting beta agonist (LABA) and requires PA.
  • Arformoterol and Serevent Diskus remain preferred LABAs and do not require PA.

Pulmicort Flexhaler is transitioning to a new manufacturer/distributor and will no longer be covered by ND Medicaid.

  • The new distributor does not participate in the Medicaid Drug Rebate Program (MDRP).
  • Please transition members to therapeutically appropriate covered alternatives.
  • ND Medicaid preferred inhaled corticosteroids that do not require PA include: 
    • Arnuity Ellipta.
    • Asmanex HFA.
    • Asmanex Twisthaler.
    • Budesonide Suspension.
    • Fluticasone HFA for members 4 years of age and younger.

ND Medicaid is not able to pay for a drug when the manufacturer does not participate in the MDRP due to federal law.

  • 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 immediately: Electronic age verification applies to Dulera claims to ensure use of approved dosing that aligns with current asthma guidelines.
Electronic age verification occurs during adjudication at the point of sale.

  • Dulera 50 mcg/5 mcg strength: Member must be age 5 years through 11 years.
  • Dulera 100 mcg/5 mcg strength: Member must be age 5 years or older.
  • Dulera 200 mcg/5 mcg strength: Member must be age 12 years or older.

Claims corner 

ND Medicaid appreciates your ongoing efforts to submit accurate and timely claims. To support efficient processing and reduce the need for internal follow-up, we are reminding providers of an important best practice when submitting adjusted claims, particularly multi-line claims or adjustments where the reason for correction may not be obvious on the face of the claim.

When an adjustment is submitted without a clear explanation of why it is being adjusted, ND Medicaid staff must spend additional time researching the original claim, reviewing system histories and determining whether the adjustment reflects a true billing correction, a duplicate or another issue. This extra processing time can delay accurate adjudication not only for us but for you as well.

To improve efficiency and support claims integrity, include a concise note in the claim’s note field explaining the reason for the adjustment.

This reduces the chances of misinterpretation that could result in an inadvertent denial. Providing the rationale within the claim helps both the provider and ND Medicaid maintain accurate records in the event a claim is reviewed during internal or external audit.