Updated: January 2026
Purpose
This policy establishes Medicaid enrollment, service delivery, billing, and reimbursement standards for:
- Indian Health Service (IHS) facilities;
- Tribal Health Programs (THPs) operating under the Indian Self-Determination and Education Assistance Act (ISDEAA); and
- Tribal Federally Qualified Health Centers (FQHCs).
The policy provides consistent guidance while honoring federal authority and the unique requirements for services provided to American Indian/Alaska Natives (AI/AN) members.
Applicability
Eligible Providers
To receive payment from ND Medicaid, the eligible servicing and billing provider National Provider Identifiers (NPI) must be enrolled with ND Medicaid on the date of service. Servicing providers acting as a locum tenens provider must be enrolled with ND Medicaid and be listed on the claim form. Please refer to provider enrollment for additional details on enrollment eligibility and supporting documentation requirements.
These providers must:
- Meet eligibility requirements; and
- Have a current and valid license or certification from either:
- The out-of-state licensing board where the license was issued; or
- An ND licensing board.
If a provider is practicing under a Tribal license or certification recognized by ND Medicaid, documentation must be kept on file and submitted upon request.
Note: Out-of-state licensed/certified providers may only affiliate with IHS or THP facilities. ND licensed/certified providers may affiliate with non-IHS and non-THP facilities. The following IHS, THP and Tribal FQHC services can be provided by the providers listed below.
An outpatient medical encounter can only be claimed for services rendered face-to-face (including synchronous telehealth) by one of the following practitioners compensated by an IHS facility/THP for the services provided:
- Physicians
- Physician Assistants
- Clinical Nurse Specialists
- Licensed Registered Dietitians
- Podiatrists
Vision encounters can only be claimed for services rendered face-to-face (including synchronous telehealth). Eligible providers include:
- Optometrists
- Ophthalmologists
A mental health encounter can only be claimed for services separate and distinct from another encounter type which are rendered face-to-face (including synchronous telehealth ) by a qualified mental health professional which includes:
- Physician
- Licensed Clinical Social Worker
- Licensed Master Social Worker
- Licensed Professional Counselor
- Licensed Professional Clinical Counselor
- Licensed Marriage and Family Therapist
- Licensed Psychologist
- Psychiatrist
- Clinical Nurse Specialist
Dental encounters include covered services and supplies. Eligible providers include:
- Dentists
Dental hygienist services rendered by hygienists working within their scope as allowed under North Dakota law, regulations, and practice guidelines, and under the appropriate level of dental supervision must be billed under the supervising dentist.
Inpatient Encounter Services
- Inpatient services provided at an IHS facility are reimbursed on a per diem basis.
Pharmacy Encounters include prescriptions dispensed by the pharmacy via point of sale and are reimbursed as follows:
- The first prescription is reimbursed at the encounter rate and any subsequent prescriptions dispensed on the same date of service are reimbursed at zero, regardless of the number of visits to the pharmacy.
A substance use disorder encounter can only be claimed for services rendered face-to-face (including synchronous telehealth) by a qualified behavioral health professional which includes:
- Licensed SUD agency
- Licensed Addiction Counselor
An EPSDT encounter can only be claimed for services rendered face-to-face in compliance with the Preventive Chronic Disease Management and Health Tracks Early and Periodic Screening, Diagnostic and Treatment (EPSDT) policy.
Enrollment
IHS Facilities
Indian Health Service (IHS) facilities may enroll with ND Medicaid to provide services reimbursable under the state plan. Enrollment requires submission of a valid National Provider Identifier (NPI), applicable state licensure or certification, and documentation verifying operation as an IHS facility under federal authority.
Tribal Health Programs
Tribal Health Programs operating under an Indian Self-Determination and Education Assistance Act (ISDEAA) contract or compact may enroll in ND Medicaid as a Tribal provider. At the time of enrollment and upon renewal, the Tribal program must submit:
- A copy of its ISDEAA contract or compact; and
- A valid National Provider Identifier (NPI).
Tribal Federally Qualified Health Centers
Tribal organizations operating under an ISDEAA contract or compact may elect to enroll as a Tribal FQHC. At the time of enrollment and upon renewal, the Tribal FQHC must submit:
- A copy of its ISDEAA contract or compact; and
- A valid National Provider Identifier (NPI).
Tribal FQHCs are not required to obtain designation through the Health Resources and Services Administration (HRSA). Instead, enrollment and reimbursement follow the standards established under the ISDEAA and the North Dakota Medicaid State Plan.
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.
Services may be provided regardless of Medicaid status, but reimbursement is only available if the individual is found eligible for Medicaid coverage for the date of service.
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.
ND Medicaid covers the same services for members who are enrolled in Medicaid and receiving services at IHS as those members who are enrolled in Medicaid only. Coverage and payment of services provided through synchronous telehealth is on the same basis as those provided through face-to-face contact.
Payment to IHS, tribal health program, and tribal FQHC facilities will be on an encounter basis using approved all-inclusive rates published each year in the Federal Register by the Department of Health and Human Services. Each encounter includes covered services by a health professional and related services and supplies.
Covered Encounters
An encounter is defined as a face-to-face or telehealth meeting between a patient and a health professional for the provision of health services to the patient. Each encounter must document a distinct service and is reimbursed at the federally established All-Inclusive Rate (AIR), unless otherwise specified by CMS.
Covered encounters include:
- Outpatient medical services;
- Vision services;
- Dental services;
- Mental health services;
- EPSDT services;
- Substance Use Disorder (SUD) services;
- Pharmacy services; and
- Inpatient services.
Each encounter includes covered services by a health professional and related services and supplies.
Listed below are services included as part of an encounter. These services are not separately billable or eligible for an encounter rate without meeting the above-listed criteria of an encounter:
- Radiology services including professional and technical component;
- Diagnostic services, including professional and technical component;
- Laboratory services including specimen collection and professional and technical component;
- Medical supplies used in conjunction with an encounter; and
- Physician administered drugs and other drugs or medications used in conjunction with an encounter including drugs or medications provided as part of an inpatient encounter.
Dental hygienist services rendered by hygienists working within their scope as allowed under North Dakota law, regulations, and practice guidelines, and under the appropriate level of dental supervision must be billed under the supervising dentist.
Encounter rates may be generated by a hygienist for the following services:
- Dental prophylaxis (full mouth);
- Periodontal maintenance services (full mouth);
- Scaling and root planning (minimum of one quadrant);
- Dental screening and assessment if provided in addition to another qualifying service; or
- Sealants, if provided with another qualifying service, as part of the school-based sealant program.
Encounter rates cannot be generated when the only service rendered by a hygienist is:
- Impressions;
- Application of fluoride varnish;
- Denture cleanings;
- Suture removal;
- Dental case management; and/or
- Any type of oral hygiene instruction or education, including nutritional counseling and smoking cessation.
A substance use disorder encounter is one during which services contained within the Substance Use Disorder Treatment Services policy is rendered. If multiple SUD based services are delivered in the same day, such as group therapy and individual therapy, only one encounter will be reimbursed. If SUD services and MH services are provided during the same encounter, the provider should bill the appropriate revenue, procedure, and primary diagnosis codes for the predominant focus of the visit.
- SUD revenue code: 0900
- Mental Health code: 0513
ASAM Level 3.1 must be received concurrently with Level 2.1 or 2.5. These concurrent services only qualify for one encounter billing for the two services.
Multiple visits for different services on the same day with different diagnoses.
IHS facilities, Tribal 638 facilities, and Tribal 638 FQHCs are eligible for multiple encounter payments for general covered service categories on the same day for the same recipient with a different diagnosis. A pharmacy service is one encounter payment regardless of how many prescriptions are filled on that day.
Multiple visits for different services on the same day with the same diagnosis.
IHS facilities, Tribal 638 facilities, and Tribal FQHCs are eligible for multiple encounter payments for general covered service categories on the same day for the same recipient with the same diagnosis provided they are for distinctly different services. The diagnosis code may be the same for each of the encounters, but the services provided must be distinctly different and occur within different units of the facility.
Multiple visits for the same type of service on the same day with different diagnoses.
IHS facilities, Tribal 638 facilities, and Tribal 638 FQHCs are eligible for multiple encounter payments for multiple same day visits for the same type of general covered service category if the diagnoses are different.
Immunizations
Immunizations administered in conjunction with a medical encounter are considered incident to the medical encounter and neither the immunization nor the immunization administration will be reimbursed in addition to a medical encounter.
When the only service provided is an immunization:
- The immunization administration can be billed, but an encounter cannot be billed. The immunization administration must be billed using Revenue Code 0771 (Immunization administration) along with the appropriate CPT® code. The claim must include Revenue Code 0636 (Drugs requiring detailed coding) and the appropriate CPT® code for the immunization.
- If the immunization is supplied by the Vaccine for Children (VFC) program, ND Medicaid will not make payment for the immunization. ND Medicaid will only make payment for the immunization administration; however, the claim must include Revenue Code 0636 (Drugs requiring detailed coding) and the appropriate CPT® code for the vaccine. If the immunization is not supplied by the VFC program and is currently covered by ND Medicaid, the immunization will be reimbursed according to the Medicaid fee schedule using the appropriate CPT® code.
Please refer to the Immunizations policy for additional information on immunizations and immunization administration.
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.
Payment Limitations
Tribal Health Programs can only bill North Dakota Medicaid for services contained within the scope of their ISDEAA contract or compact.
Encounters with more than one health professional and/or multiple encounters with the same health professionals on the same day and at a single location constitute a single visit except when one of the following conditions exist:
- Multiple visits for different services on the same day with different diagnosis.
- Multiple visits for different services on the same day with the same diagnosis. The diagnosis code may be the same on the claims, but the services provided must be distinctly different and occur within different units of the facility. An example of this is when a member sees a medication prescriber for a prescription and then sees a mental health professional for the same diagnosis.
- Multiple visits for the same type of service on the same day with different diagnosis. For example, after the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment (excluding prescriptions).
All dental encounter services must be submitted with revenue code 0512. Dental Case Management must be billed in addition to another qualifying dental service to receive reimbursement for the encounter.
Claim Form
Encounter services must be billed using the UB 04 claim form or 837i HIPPA compliant form. Services outside of the encounter rate should be billed on the 837p claim form or 837p HIPPA compliant form. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.
Effective January 1, 2026, all IHS providers must report all services provided during the encounter visit on the claim. Services that do not generate an encounter payment must be submitted for quality reporting and informational purposes.
Claim Requirements
IHS and THP claims must be submitted to ND Medicaid using the following Revenue Codes when billing for:
- Revenue Code 0100 Inpatient In-House Medicaid Days
- Revenue Code 0490 Ambulatory Surgical Center
- Revenue Code 0500 Outpatient
- Revenue Code 0509 Vision
- Revenue Code 0512 Dental
- Revenue Code 0513 Mental Health
- Revenue Code 0519 Health Tracks/EPSDT well-child check
- Revenue Code 0900 Substance Use Disorder
- Revenue Code 0987 Physician Inpatient Services
Reference the Telehealth policy for specific billing instruction related to services rendered via telehealth.
A procedure code must be billed with revenue codes that require a CPT® /HCPC code according to NUBC guidelines.
Services outside of an encounter
The following services occur outside of an encounter and must be billed pursuant to the appropriate fee-for-service fee schedule:
- Ambulance services;
- Non-Emergency Medical Transportation;
- Targeted Case Management;
- Home and Community-Based Waiver Services;
- 1915(i) Behavioral Health Supports & Services;
- Home Health Visits;
- Nursing Facility Visits;
- Community Health Worker services; and
- Community Paramedic services.
Note: The above-listed services must be billed through a separate Medicaid provider enrollment and cannot be billed through an IHS or Tribal Health Program or Tribal FQHC enrollment.
Services provided under a Care Coordination Agreement
The federal government matches state expenditures for covered services “received through” an IHS facility or tribal health program as defined in this policy at 100% Federal Medical Assistance Percentage (FMAP) rate. Services not “received through” an IHS or THP are matched at the state’s regular FMAP rate. The scope of service considered “received through” an IHS or THP facility includes any services that the facility is authorized to provide according to IHS rules and that are also covered under the North Dakota Medicaid state plan.
Services “received through” an IHS or THP facility include covered services requested in accordance with a written care coordination agreement.
Please refer to the Care Coordination Billing Guidelines and Tribal Care Coordination Guidance for more information.
Definitions
Encounter – means a face-to-face visit or synchronous telehealth visit during which a qualifying encounter service is rendered. Lab or x-ray services with no face-to-face visit with a qualifying provider are not reimbursed separately from the original encounter from which these tests or services were ordered.
Tribal health program (THP) – means an Indian tribe or tribal organization that operates any health program, service, function, activity, or facility funded, in whole or part, by the Indian Health Service (IHS) through, or provided for in, a contract or compact with IHS under the Indian Self-Determination and Education Assistance Act (ISDEAA) (25 U.S.C. 5301 et seq.). Tribal health programs in this policy means a 638 facility that has not elected to be a Tribal FQHC.
Tribal FQHC – Operating as an outpatient health program or facility of a tribe or tribal organization under the Indian Self-Determination and Education Assistance Act (ISDEAA) or as an urban Indian organization getting funds under Title V of the Indian Health Care Improvement Act as of October 1991. Tribal health programs/638 facilities can elect to be Tribal FQHCs.
References
Related Policies
Contact
Medical Services
600 East Boulevard Ave
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov
Policy Updates
January 2026
- Claim Form
- New billing guidelines effective 01/01/2026
- Format and ADA clarifications added throughout the document.