Updated: July 2026
Purpose
This policy defines situations in which ND Medicaid will provide reimbursement for induced or therapeutic abortion services. This policy does not apply to the treatment of miscarriage or natural expulsion of a pregnancy.
Applicability
Eligible Providers
To receive payment from ND Medicaid, the eligible servicing and billing providers must be enrolled with ND Medicaid on the date of service, and their National Provider Identifiers (NPIs) must be active in their Medicaid enrollment records. Servicing providers acting as a locum tenens provider must be enrolled with ND Medicaid, and services they provide must be billed with their NPI. Please refer to provider enrollment for additional details on enrollment eligibility and supporting documentation requirements.
Eligible Members
Providers are responsible for verifying a member’s eligibility before providing services. Eligibility can be verified using the ND Medicaid MMIS Portal or through the Automated Voice Response System by dialing 1.877.328.7098.
Refer to the Member Eligibility Manual for additional information regarding eligibility, including information regarding limited coverage categories.
Covered Services and Limits
General Provider Policies
The General Provider Policies details basic coverage requirements for all services. Basic coverage requirements include:
- The provider must be enrolled in ND Medicaid;
- Services must be medically necessary;
- The member must be eligible on the date of service; and
- If applicable, the service has an approved service authorization.
The Procedure Code Look-up Tool can be used to identify if a procedure code is covered by ND Medicaid, along with code-specific details such as ORP requirements, Service Authorization requirements, and current rates.
Abortions to Save the Life of the Woman
An abortion deemed necessary based on reasonable medical judgment, intended to prevent the death or a serious health risk to the pregnant woman. The treating physician must provide a signed written statement that, in the physician’s professional judgment, the life of the woman would be endangered if the fetus were carried to term. The statement must contain the reasons why the physician believes the life of the woman would be in danger if the fetus were carried to term.
Abortions that are a Result of an Act of Rape or Incest
If a member reports an act of rape or incest to an appropriate law enforcement agency or, in the case of a minor who is a victim of incest, to an agency authorized to receive child abuse and neglect reports, the physician must provide ND Medicaid with a signed written statement indicating that the rape or act of incest has been reported and to whom the report was made.
If the rape or act of incest was not reported to an appropriate agency, the member must sign a written statement indicating her current pregnancy resulted from either an act of rape or incest. The treating physician must provide a signed written verification that, in the physician’s professional judgment, the woman’s pregnancy resulted from rape or incest.
Treatment for infection or other complications of the abortion is a covered service.
Service Authorization Requirements
No service authorization required when performed in the state or within 50 miles of the North Dakota border.
Out-of-state services must follow the out-of-state authorization process.
Noncovered Services
General Noncovered Services
The Noncovered Services Policy contains a general list of services that are not covered by North Dakota Medicaid.
Noncovered Abortion Services
- Any induced abortion performed for reasons other than rape, incest, or the life of the mother.
- Any induced abortion performed where the documentation does not meet Medicaid criteria listed in this policy.
Documentation Requirements
General Requirements
Providers must keep legible medical and financial records that fully justify and disclose the extent of services provided and billed to ND Medicaid. Records must be retained for at least 7 years after the last date the claim was paid or denied. Providers must follow the documentation requirements in the Provider Requirements Policy.
Medical Documentation Supporting Covered Service
All claims for an abortion must be accompanied by documentation that establishes the reason why it was necessary to perform the abortion. Information provided by the physician will be reviewed by the Medical Services Division's medical consultant and the director of Medical Services to ensure the abortion was necessary to save the life of the woman or was the result of an act of rape or incest. If the supplied documentation meets ND Medicaid guidelines, payment will be approved. Payment will be denied if the documentation does not meet these guidelines or is not provided.
Reimbursement Methodology and Claim Instructions
Timely Filing
ND Medicaid must receive an original Medicaid primary claim within one hundred eighty (180) days from the date of service. The time limit may be waived or extended by ND Medicaid in certain circumstances. The Timely Filing Policy contains additional information.
Third-Party Liability
Medicaid members may have one or more additional sources of coverage for health services. ND Medicaid is generally the payer of last resort. Providers must pursue the availability of third-party payment sources. The Third Party Liability Policy contains additional information.
Client Share (Recipient Liability)
Client share (recipient liability) is the monthly amount a member must pay toward the cost of medical services before the Medicaid program will pay for services received. The Client Share Policy contains additional information.
Reimbursement
A claim for services must be submitted at the provider’s usual and customary charge. Payment for services is limited to the lesser of the provider’s usual and customary charge or the ND Medicaid calculated reimbursement.
Claim Form
Professional services must be billed electronically via an 837P transaction. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.
Claim Requirements
Claims for abortion services must be submitted with an attachment containing the required documentation.
The ordering, referring, or prescribing provider’s NPI must be listed on the claim for any labs, imaging, or physician-administered drugs billed in addition to the procedure.
Definitions
Induced abortion – any pregnancy that is intentionally terminated through medical intervention. It can be performed through medication or surgery.
Therapeutic abortion – induced abortions that are performed when there is a serious medical risk to the pregnant person.
References
Related Policies
Frequently Asked Questions
Induced abortion – any pregnancy that is intentionally terminated through medical intervention. It can be performed through medication or surgery.
Therapeutic abortion – induced abortions that are performed when there is a serious medical risk to the pregnant person.
Contact
Medical Services
600 East Boulevard Ave
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov
Policy Updates
July 2025
- Format changes and clarifications added throughout.
April 2026
- Format changes made throughout.
July 2026
- Removed CMS 1500 from the Claim Requirements section. All claims must be submitted electronically.