Dual Eligibles

Updated: January 2026

Purpose

Crossover claims are claims for a member who is eligible for ND Medicaid and Medicare, including Medicare Advantage (Part C) Plans, Dual Special Needs Plans (D-SNP) and Medicare Supplemental (Medigap/Extended) Plans. 

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.

• Members who are eligible for Medicaid and Medicare.

Members enrolled in the federally administered Medicare program are referred to as dual eligible. Medicare currently consists of four parts: 

• Medicare Part A includes coverage for inpatient hospital care, skilled nursing facility, hospice, lab tests, surgery, home health care; 
• Medicare Part B includes coverage for doctor and other health care providers' services, outpatient care, durable medical equipment, home health care and some preventive services;
• Medicare Part C (Medicare Advantage) combines coverage of Medicare Part A, B, and D includes other supplemental benefits like vision and dental. Dual Special Needs Plans (DSNP) are a type of Medicare Part C coverage; and
• Medicare Part D is prescription drug coverage.

Medicare is the primary insurer for all dual eligible members. Medicaid may be required to pay some or all the member's Medicare premium, deductible, and coinsurance costs, depending on if the member is eligible under one of the following types of Medicare Savings Programs:

• Qualified Medicare Beneficiaries (QMB): Medicaid will pay Part B premiums, Part A premiums (in some instances), deductibles, coinsurance and copayments (for services and items Medicare covers).
• Special Low-Income Medicare Beneficiaries (SLMB): Medicaid will pay the Part B premium only. These individuals cannot be eligible for Medicaid.
• Qualifying Individual (QI1): Medicaid will pay Part B premium only. These individuals cannot be eligible for Medicaid.

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. 

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.

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 claims must be billed using the CMS 1500 claim form or the HIPAA compliant 837p form. Institutional claims must be billed using the UB04 claim form or the HIPAA compliant 837i form. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.