Rates and Fee Schedules

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Facility Cost Reporting

Procedure Code Look-up Tool

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North Dakota Medicaid rates and fee schedules are organized below by provider type. Rate and fee schedules serve as an informational resource for providers and do not guarantee payment at the specific rate or fee listed. North Dakota Medicaid requires all providers to bill their usual and customary charges for services provided to Medicaid members. Providers should not use North Dakota Medicaid reimbursement to set rates. "Usual and customary charge" means the provider's charge for providing the same service to the general public.

Rates

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Rates

Fee Schedules

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Fee Schedules

Fee Schedule Information and Instructions

Each fee schedule lists:
- Procedure code the numerical identifier (generally CPT or HCPCS) for medical services or supplies.
  - The publication of a fee or code does not guarantee coverage under North Dakota Medicaid. Providers and members should review North Dakota Medicaid policy and guidance for details on coverage criteria.
  - The exclusion of a procedure code does not necessarily mean the procedure code is not a covered service. Codes without a set price are not listed on North Dakota Medicaid fee schedules, but may be manually priced, reimbursed based on invoice, or be reimbursed at zero.
- Reimbursement allowable amounts for the procedure code.
  - For most services, North Dakota Medicaid reimburses the lesser of:
    - the billed amount; or
    - the maximum allowable fee established by North Dakota Medicaid.
  - North Dakota Medicaid requires all providers to bill their usual and customary charges for services provided to Medicaid members. Providers should not use the fee schedule to set rates. "Usual and customary charge" means the provider's charge for providing the same service to the general public.
All coverage limits and prior authorizations apply.
- Any listed code may be subject to service limitations or require prior authorization from North Dakota Medicaid or its designee.
Allowed amounts are current as of the date indicated on the fee schedule. Reimbursement rates may change during the year without an update occurring to the internet fee schedule information. North Dakota Medicaid notifies impacted providers of rate/fee changes via letters and web updates.
The use of required modifiers may result in a different fee from the published fee, as some modifiers affect pricing (e.g., professional component modifier, bilateral procedure modifier, etc.).
Fees are listed for Professional Services (physicians, etc.). Not all fees across provider types are listed; allowable amounts may vary for the same code, depending on the provider type.
The fee schedules are maintained in a series of .CSV files, updated weekly. These files are refreshed every Sunday to ensure that all pricing and fee information reflects the most current and accurate data available. Users should reference the latest Sunday update when reviewing or applying the fee schedule to ensure consistency and compliance with current rates and code information.
Each file contains the same information as the Procedure Code Look-up Tool.
- CPT or HCPCS code, short description, and Category
- Coverage and coverage notes
- Telehealth applicability
- Modifier requirements
- Medicaid Allowed Amount
  - Professional (-26 modifier)
  - Technical (-TC modifier)
  - Rental DME
  - Purchase DME
  - General Rate (includes total component for diagnostic services)
  - Adult and Child Dental
- ASC applicability
- Encounter applicability for FQHC, RHC, and IHS
- Ordering, Referring, and Prescribing Requirement Information
- Service Authorization information
- Local and National Coverage Determination (LCD/NCD) applicability