To comply with the Centers for Medicare and Medicaid Services' Interoperability and Prior Authorization final rule, North Dakota Medicaid is required to post service authorization metrics annually. This includes a list of covered items and services (excluding drugs) that require a service authorization along with data related to service authorization approvals and denials for the previous calendar year.
Items and services requiring a service authorization
North Dakota Medicaid requires a service authorization for certain procedures, services and items before being initiated, supplied or performed. Some services may need a service authorization to exceed limits as well. Service 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 Service Authorization Excel spreadsheet for a complete list of procedure codes that require a service authorization.
Service 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 service authorizations – Service authorizations submitted up to 90 days after the initial date of service.
Standard (non-urgent) service 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) service 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 service 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) service authorization request (response due to provider within 72 hours)
Mean (average) days
- 0
Median (middle) days
- 0