Forensic Examinations

Updated: April 2026

Purpose

ND Medicaid covers an initial medical forensic examination for suspected physical abuse of an adult or child.

Please see the Behavioral Health Rehabilitative Services policy for information related to Assessment for Alleged Abuse and/or Neglect and Recommended Plan of Care (formerly known as Forensic Interview).

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.

Forensic exams can be provided by the following enrolled providers as allowed by their scope of their licensure:

Physicians
Nurse Practitioners
Physician Assistants

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.

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.

Forensic medical examinations (acute forensic medical examination and child forensic medical examination) performed on an alleged victim of criminal sexual conduct to gather evidence of an alleged crime are not covered by ND Medicaid. Please see N.D.C.C.§ 12.1-34-07 for information about reimbursement for these examinations from the ND Attorney General.

A preliminary medical screening exam conducted in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA) before an acute forensic medical examination or a child forensic medical examination is not covered by ND Medicaid. Please see N.D.C.C.§ 12.1-34-07 for information about reimbursement for these examinations from the ND Attorney General.

Exception: A preliminary medical screening exam performed for a North Dakota Medicaid-eligible individual who is an alleged victim of criminal sexual conduct, which allegedly occurred in a state other than North Dakota, is billable to 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 Polic y 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

Forensic exam professional services must be billed using the CMS 1500 claim form or 837p. Institutional or facility services related to the forensic exam must be billed on the CMS UB-04 form or 837i. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.

Claim Requirements

Forensic exams should be billed with the appropriate level E/M CPT© Code 99202-99215 appended with modifier 32, including one of the following ICD10-CM codes:

T76.12xA – Child Physical Abuse, suspected, initial encounter.
Z04.72 – Encounter for examination and observation following alleged child physical abuse.

References

Contact

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