To comply with the Centers for Medicare and Medicaid Services' Interoperability and Prior Authorization final rule, North Dakota Medicaid is required to post prior authorization metrics annually. This includes a list of covered items and services (excluding drugs) that require prior authorization along with data related to prior authorization approvals and denials for the previous calendar year.
Items and services requiring a prior authorization
North Dakota Medicaid requires a prior authorization for certain procedures, services and items before being initiated, supplied or performed. Some services may need a prior authorization to exceed limits as well. Prior authorizations ensure members receive the care they need and that it's medically necessary.
- Applied behavioral analyses (autism services)
- Dental
- Durable medical equipment, including supplies, prosthetics and orthotics
- Hearing aids and related services
- Home health
- Hospice
- Labs including genomic sequencing procedures, multianalyte assays, proprietary laboratory analyses, tier 1 and 2 molecular pathology
- Photodynamic services
- Physical medicine services, including physical and occupational therapy
- Private duty nursing
- Surgical procedures related to:
- Auditory system
- Digestive system
- Eye and ocular adnexa
- Female genital system
- Integumentary system
- Male genital system
- Musculoskeletal system
- Nervous system
- Respiratory system
- Urinary system
- Vision services including eyeglasses, frames and lenses.
Refer to the Prior Authorization Excel spreadsheet for a complete list of procedure codes that require a service authorization.
Prior authorization definitions
- Standard (non-urgent) request - Prior authorization completed within seven calendar days.
- Expedited (urgent) request - Prior authorization completed within 72 hours.
- Request approved - The prior authorization request is approved.
- Request denied - The prior authorization request is denied.
- Retroactive authorizations – Prior authorizations submitted up to 90 days after the initial date of service.
Standard (non-urgent) prior authorization requests
Requests submitted
- 20,383
Requests approved
- 15,023 or 73.70%
Requests denied
- 5,360 or 26.30%
Requests partially denied
- 0
Requests approved only after time for review was extended
- 0
Expediated (urgent) prior authorization requests
Requests submitted
- 0
Requests approved
- 0
Requests denied
- 0
Requests partially denied
- 0
Requests approved only after time for review was extended
- 0
Time between receiving a prior authorization request and sending a decision
Standard (non-urgent) prior authorization request
Mean (average) days
- 2.36 days
Median (middle) days
- 1.18 days
Expediated (urgent) prior authorization request (response due to provider within 72 hours)
Mean (average) days
- 0
Median (middle) days
- 0