Updated: July 2026
Purpose
ND Medicaid covers cardiac rehabilitation services provided by a cardiac rehabilitation program approved by and enrolled with Medicare. Services of non-physician personnel must be furnished under the direct on-site supervision of a physician.
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.
Cardiac Rehabilitation services can be provided by the following enrolled providers as allowed by their scope of their licensure:
- Physician;
- Physician Assistant (PA);
- Nurse Practitioner (NP); and
- Clinical Nurse Specialist (CNS).
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.
Cardiac rehabilitation is defined as a recovery program consisting primarily of monitored cardiac exercise or therapy with member instruction and diagnostic testing services.
The member must undergo a comprehensive base line assessment to evaluate coronary risk factors and exercise capacity. Cardiac rehabilitation staff must review the assessment to outline a medically necessary and realistic individual program with short and long-term goals. Cardiac rehabilitation services are designed to be an aftercare program which is covered for members recovering from:
- Myocardial Infarction in the last 12 months;
- Coronary artery bypass surgery;
- Coronary angioplasty with or without stent;
- Valve replacement/repair surgery;
- Stable chronic heart failure;
- Heart and heart/lung transplant and/or have;
- Stable angina pectoris; or
- Ventricular assistive device.
A physician must be immediately available for an emergency at all times when an exercise program is being conducted.
ND Medicaid will only cover cardiac rehabilitation services that are provided by a Medicare-approved cardiac rehabilitation program. Services must be considered reasonable and necessary. ND Medicaid will cover up to 36 sessions consisting typically of three sessions per week in a single 12-week period.
At least one of the following services must be included in a cardiac rehabilitation session and are not separately payable:
- A new patient comprehensive evaluation. The exam should include a history, physical, and an initial exercise prescription. If the exam has already been performed by the member’s primary care provider, the medical record must support the need for a repeat examination including documenting that the exam rendered by the attending primary care provider is not acceptable to the cardiac rehab program director;
- A limited examination to adjust medication, treatment, or therapy;
- ECG rhythm strip with interpretation and revision of exercise therapy;
- Exercise therapy with continuous ECG telemetric monitoring (excludes physical therapy and occupational therapy); or
- Diagnostic and therapeutic services that are reasonable and necessary to perform cardiac rehabilitation services safely and effectively.
The following services, based on individualized medical needs, may be billed separately:
- Behavioral health services;
- Laboratory services that are not performed to monitor the member’s cardiac condition and cardiac rehabilitation program progress;
- ECG stress tests – one is usually performed at the beginning of the program and after three months or at the completion of the program. Performance of these tests more frequently requires medical record documentation demonstrating medical necessity;
- Medical Nutritional Therapy (See Medical Nutrition Therapy in the Preventive Services policy);
- Other services provided by a physician, nurse practitioner, physician assistant or clinical nurse specialist:
- To provide medical care for diagnoses or conditions that are not a part of cardiac rehabilitation;
- To interpret and report on ECG stress testing; and
- To evaluate complications of cardiac rehabilitation.
Service Authorization Requirements
No service authorization required.
Noncovered Services
General Noncovered Services
The Noncovered Services Policy contains a general list of services that are not covered by North Dakota Medicaid.
Noncovered Cardiac Rehabilitation Services include:
- Services provided absent Medicare approval of the cardiac rehabilitation program;
- Formal lectures and counseling on health education that are normally furnished by the attending physician following a member’s acute cardiac episode; and
- Physical therapy and occupational therapy when furnished in connection with a cardiac rehabilitation program - unless there is also a non-cardiac diagnosis requiring such therapy.
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.
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 source 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 using the CMS 1500 claim form or 837p and institutional services must be billed using the UB04 claim form or 837i. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.
References
Contact
Medical Services
600 East Boulevard Ave
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov
Policy Updates
July 2025
- Format updates and clarifications added throughout the policy.
April 2026
- Formatting changes made throughout the policy.
July 2026
- ADA updates throughout the policy.