Covered Services

Updated: April 2026

Purpose

This policy contains general information about services covered by Medicaid.

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.

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 ordering/referring/prescribing requirements, Service Authorization requirements, and current rates.

The following services are covered by ND Medicaid. Further information about these services can be found in the corresponding policy on the Provider Guidelines, Manuals, and Policies webpage. Covered services are subject to change based on changes in funding, legislative action, and changes in administrative rules. 

  • Covered services include:
  • 1915(i) Services;
  • Ambulance services;
  • Ambulatory surgical services;
  • Audiology;
  • Autism Spectrum Disorder Applied Behavioral Analysis (ABA) Services;
  • Certified nurse midwife services;
  • Chiropractic services;
  • Dental services;
  • Durable medical equipment, medical supplies, prosthetic providers, hearing aids;
  • Emergency Services, and follow-up care;
  • Family planning;
  • Federally qualified health centers (FQHC);
  • Health Tracks (EPSDT) Screening;
  • Home and community-based services (HCBS waiver);
  • Home health care services;
  • Hospice;
  • Hospitals (inpatient);
  • Hospital services;
  • Swing bed services;
  • Immunizations;
  • Inpatient psychiatric services;
  • Intermediate care facilities for individuals with intellectual disabilities (ICF/IID);
  • Laboratory services;
  • Local Public Health Units (LPHU);
  • Medical Nutritional Therapy;
  • Medication Therapy Management (MTM);
  • Nonemergency medical transportation (NEMT);
  • Nurse practitioner services;
  • Nursing facility services;
  • Occupational therapy;
  • Optometric services;
  • Orthodontia;
  • Partial hospitalization program;
  • Personal care services in a member’s home;
  • Pharmacy;
  • Physical therapy;
  • Physician services, Primary Care;
  • Physician Services, Specialty Care;
  • Podiatry;
  • Private duty nursing;
  • Nursing;
  • Psychiatric Residential Treatment facilities (PRTF);
  • Radiology;
  • Behavioral Health Rehabilitative Services;
  • Rural health clinics (RHC);
  • School-based Services (Individualized Education Plans (IEPS) and Non-IEPs);
  • Speech therapy;
  • Substance Use Disorder Treatment Services; and
  • Targeted case management.

Noncovered Services

General Noncovered Services

The Noncovered Services Policy contains a general list of services that are not covered by North Dakota Medicaid.

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.

References

Related Policies

Contact

Medical Services
600 East Boulevard Ave Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov

Policy Updates

October 2025

  • Covered Services and Limits
    • Removed the entire column titled “Referral Required from Primary Care Provider due to PCCM Program ending December 2023. Replaced “serious mental illness, severe emotional disturbance” with behavioral health in the Targeted Case Management row.
  • Format changes and clarifications added throughout.

April 2026

  • Covered Services and Limits
    • Replaced services table with list of covered services.
  • Formatting changes made throughout.