ND Medicaid Provider Newsletter - September 2026

Upcoming Medicaid eligibility changes

As a trusted provider, you play an important role in the health and well-being of Medicaid members. We want you to be aware of some upcoming federal Medicaid policy changes that may impact some of your patients.

Oct. 1, 2026
Applies to all Medicaid members
The federal law changed who is considered a qualified immigrant for Medicaid. Starting Oct. 1, 2026 eligible non-citizens will be:

• Lawful Permanent Residents (LPR’s/green card holders): Certain statuses may be subject to 5 year waiting period and 40 work quarter requirements.
• Cuban/Haitian entrants.
• Compacts of Free Association (COFA) which includes the Federal States of Micronesia, the Marshall Islands, or Palau.

Jan. 1, 2027
Applies to Medicaid Expansion members with Blue Cross Blue Shield North Dakota coverage

• Some adults ages 19-64 will be required to work, go to school, take part in job training or a work program or volunteer for 80 hours in a month to keep their coverage. Some people will be excluded from meeting the requirements. 
• Retroactive coverage will go from three months to one month at application time. 
• People will be required to renew their coverage every six months instead of 12 months. 

Jan. 1, 2027
Applies to traditional Medicaid members (fee for service)

• Retroactive coverage will go from three months to two months at application time.

Learn more
Work requirements, visit hhs.nd.gov/StayCoveredND. 
Other federal Medicaid policy changes, visit hhs.nd.gov/StayEnrolled.

Service authorization changes for flexible eyeglass frames

As of Oct. 1, 2026, service authorizations will no longer be required for flexible eyeglass frames for members age five and under. For members age six and older, a service authorization will still be required when flexible eyeglass frames are medically necessary due to a diagnosis requiring additional safety or durability.

Please refer to the Optometric and Eyeglass Services policy for updated guidance following the Oct. 1, 2026 implementation date.

Updates from Quality Outreach

The importance of billing and coding in quality

It’s important to ask the patient for their Medicaid number, which can be found on their acceptance letter or their Medicaid card. Their Medicaid card should be received within 60 days. If not, the patient can call 1-866-614-6005 or email applyforhelp@nd.gov to request one.

To ensure providers get the credit they deserve, and that we have accurate claims data regarding patient’s wellness visits, it’s important to bill Medicaid, even for $0 claims. This may happen if a patient has a third-party insurance/liability.

CPT Category II Codes are extra tracking codes that help collect quality measure related information about our members. Our Quality Measure Tip Sheet is a resource to help you collect this important information.

EPSDT (Early and Periodic Screening, Diagnostic & Treatment) benefit coding and billing

We encourage all providers to use the procedure look up tool available on our website. The tool is always up to date with the most current Medicaid coding and billing information, including EPSDT benefits. You can find the Procedure Lookup Tool on our ND Medicaid Provider Information page along with information about how to use the tool as well as contact information for questions.

It’s important to check for the most recent policies and guidelines

You will find the updated policies and guidelines in the Manuals and Guidelines section of the Medicaid website.

• Please note there is a new ADA compliant SFN 61 form (EPSDT Comprehensive Orthodontic Screening) available now on our website. 
• To find the most recent orthodontia policy, please visit the Medicaid policy for orthodontics.
• We have a new Orthodontic Screening training available on NDTRAIN. Check it out here Orthodontic Screening. You will need to set up an account if you do not have one already.

If you or your team have questions regarding Medicaid wellness or EPSDT benefits and education, please contact our team at dhsmedicaidquality@nd.gov. You can also find
information regarding EPSDT (wellness visits) benefits on our wellness visits for providers webpage. 

Rural Health Transformation Program wraps up year one, looks ahead to year two

As year one of North Dakota’s Rural Health Transformation Program (RHTP) wraps up, we’re looking ahead with excitement to year two. Year one funding opportunities continue to move through the review and approval process, and we look forward to announcing awards and seeing these investments begin to take shape across rural North Dakota.

With year two beginning in October, there’s much more to come. Subscribe to RHTP news to stay up to date on award announcements, upcoming funding opportunities and the latest program news.

Preparing for the PERM RY28 review cycle

Every three years the Centers for Medicare & Medicaid Services (CMS) conducts the Payment Error Rate Measurement (PERM) audit. PERM is a federal program that focuses on reducing improper payments in Medicaid and the Children’s Health Insurance Program (CHIP). CMS developed PERM to ensure federal funds are used appropriately by calculating the percentage of payments that do not meet statutory, regulatory or administrative requirements. This is not a fraud rate; it includes administrative errors, provider noncompliance or missing documentation.

PERM audits three main areas 

• Medical record reviews
• Claims processing/payment
• Eligibility Determinations

The upcoming Reporting Year (RY) 28 cycle will review Medicaid and CHIP payments made in RY 2028 for July 1, 2026, through June 30, 2027. As providers for North Dakota Health and Human Services (HHS), you may be sent a record request from PERM in the coming months. The claims that PERM reviews are randomly chosen and require providers to submit the records requested.

Providers can use these tips to minimize the impact of a PERM audit:

• Check/update facility contacts in the state MMIS system.
• Make sure staff are aware that the RY28 PERM audit record requests are not spam.
• Make sure clinic staff are aware of this too.
• Respond in a timely manner to the request.
• Be prepared to either re-submit or send additional information as needed.

Because the PERM review is based on a random sample, not every provider will receive a letter. The letters from PERM will have HHS contact information and providers can reach out with questions or concerns. The PERM requirement is federally based, but its impact can be reduced, as long as clinics and providers respond in a timely manner. If providers have questions on the upcoming RY28 PERM audit, they can contact HHS and be put in contact with the appropriate staff.

Closing a clinic and the seven-year record rule

The provider requirements policy states that all patient records must be kept for a minimum of seven years from the date of their creation or the date when they were last in effect, whichever is later. The moving, selling or closing of a clinic does not change this requirement, because any record can still be part of an audit. Providers who close clinics need to retain records, make them available upon request and be able to be contacted.

ND Medicaid conducts routine documentation reviews to verify that billed services were delivered, properly documented and compliant with state and federal requirements. Responding to these requests is mandatory. Failure to comply may result in recoupment, audit findings or administrative sanctions.

Per North Dakota Administrative Code 75-02-05-04, providers are required to make documentation available to the North Dakota Health and Human Services (HHS) upon request.

The closing of a clinic, no matter the reason, can complicate HHS  ability to successfully obtain provider documentation. The ability to contact providers for documentation review is a cornerstone of the audit and oversight process. Providers who retire, close a clinic or cease to practice are still held to the seven-year standard and are encouraged to comply with this requirement. 

Providers should remember the following:

• Responding to ND Medicaid documentation requests is mandatory. 
• Providing records for oversight is permitted under HIPAA. 
• Documentation requests help ensure accurate billing and protect program integrity.
• Timely, complete responses help prevent recoupments and compliance issues.

Pharmacy updates

The following drugs will require service authorization effective for dates of service on and after July 1, 2026. 

Claims corner

Establishing an organization administrator

It is the responsibility of the organization administrator to self-manage the staff members’ users’ account access to MMIS Web Portal. North Dakota Medicaid strongly encourages all Medicaid providers to establish, at a minimum, one primary and one back-up organization administrator.

Effective Feb. 10, 2024, if a users’ account has not been active in 365 days, the MMIS Web Portal system will automatically terminate the users’ account. Users must sign into their account to prevent the user’s account to be terminated.

Paper claims submission tips

To help ND Medicaid process claims efficiently, do not use staples when submitting paper claims or supporting documentation. Instead, if pages need to be kept together, please use paper clips, binder clips or no fastener, if possible. Staples can damage scanning equipment and delay claim processing.