Updated: January 2026
Purpose
This policy explains covered and non-covered services and billing instructions for services provided to ND Medicaid members by local public health units.
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.
Enrolled Local Public Health Units (LPHUs) are clinics that provide public health services to a community focusing on disease prevention. During enrollment, LPHU clinics are assigned Provider Type 26—Agency and Provider Specialty 416/Taxonomy- 261QP0905X State/Local Public Health.
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.
Covered LPHU Services include:
Nursing Services
T1001
- Nursing Assessment/Evaluation
T1002
- RN services, up to 15 minutes
T1003
- LPN/LVN services, up to 15 minutes
T1015
- Clinic visit/encounter, all-inclusive service (Optimal Pregnancy Outcome Program)
T1030
- Nursing care, in the home, by RN, per diem
T1031
- Nursing care, in the home, by LPN, per diem
Preventive Services
S0302
- Completed Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service (Health Tracks Screening)
96110
- Developmental screening
96127
- Brief emotional or behavioral assessment
96161
- Maternal Depression Screening
99188
- Topical application of fluoride varnish (ages 6 months through 20 years only) Application of fluoride varnish performed in a non-dental clinic or facility setting is covered for members ages 6 months through 20 years old. A maximum of two (2) applications per year, per member is covered. It is recommended the fluoride varnish be applied at the time of a Health Tracks/well-child check.
97802
- Medical nutrition therapy; initial assessment and intervention, individual, face-to-face w/ patient, each 15 minutes
97803
- Medical nutrition therapy, re-assessment and intervention, individual, face-to-face w/ patient, each 15 minutes
97804
- Medical nutrition therapy, group (2 or more individuals), each 30 minutes
G0270
- Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes
G0271
- Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes
S0390
- Routine foot care
92558
- Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis (effective 01/01/2025 this code may be billed in addition to S0302)
99173
- Screening test of visual acuity, quantitative, bilateral (effective 01/01/2025 this code may be billed in addition to S0302)
Other Services
T1013
- Sign language or oral interpretive services, per 15 minutes
69209
- Removal impacted cerumen using irrigation/lavage, unilateral
69210
- Removal impacted cerumen, unilateral or bilateral
92567
- Tympanometry (impedance testing)
95115
- Professional service for allergen immunotherapy not including provision of allergenic extracts; singe injection
95117
- Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections
96372
- Therapeutic, prophylactic, or diagnostic injection (specify the material injected); subcutaneous or intramuscular (IM)
Laboratory Services
36415
- Collection of blood by venipuncture
36416
- Collection of capillary blood specimen (e.g. finger, heel, ear stick)
81025
- Urine pregnancy test, by visual color comparison methods
83655
- Assay of lead
85018
- Hemoglobin
85610
- Prothrombin time
86703
- Antibody; HIV-1 and HIV-2, single result
Immunizations
Please refer to the Immunization policy for complete information.
School-Based Services
Individualized Education Program (IEP)
Services provided to Medicaid-eligible children in a school setting that are authorized or prescribed in the child’s IEP must be billed to ND Medicaid by the school district. LPHUs may not bill for IEP services directly but may contract with the school district to provide services billed by the school. Refer to the School-Based Medicaid policy for more information.
Non-IEP Services
Covered services provided by a LPHU in schools must not duplicate services that are the responsibility of the school. Services that may be billed by a LPHU include:
- Chronic condition management;
- Medication administration for medication prescribed by a health care provider;
- Health screenings;
- Immunization administration; and
- Other medically necessary services that meet the definition in ND Administrative Code 75-02-02-03.2(10).
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 services provided by a LPHU include:
- Mass screenings, i.e., lice check, hearing screenings, and scoliosis screenings;
- Administration of over-the-counter medication (supervision of oral medication);
- Services that could be completed by a nonhealthcare professional; examples include:
- Administration of over-the-counter medication for discomfort or a minor ache or pain; or
- Offering snacks for dizziness or a stomachache due to hunger.
- Routine first aid, including care for minor scrapes, headaches, and other small ailments;
- Any service that is less than the minimum time for time-based codes (8 minutes for 15-minute codes and 23 minutes for 30-minute codes);
- Services that are provided without required documentation; and
- Services that are not medically necessary.
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.
Enrolled LPHU reimbursement is based on the Professional Fee schedule, which is in effect on the service date.
Claim Form
Local Public Health services must be billed using the CMS 1500 claim form or 837P. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.
Claim Requirements
LPHU claims may submit the LPHU billing NPI as the rendering provider if the LPHU is only staffed by RNs or LPNs. If the LPHU employs a mid-level provider (ex. CNP or PA) that individual must be listed as the rendering provider for any services provided by the LPHU.
LPHUs must maintain a current/valid CLIA certificate in their enrollment file to be reimbursed for laboratory services.
References
Related Policies
Frequently Asked Questions
School Services
Question (Q): If a student presents with a headache and medication is administered and the student is sent back to class, is that a billable service?
Answer (A): Medication administration of nonprescribed medication is not a billable service.
Q: If a student is diabetic and presents for assistance with blood sugar control, is this a billable service?
A: Yes, helping a student regulate their blood sugar related to a diabetes diagnosis is a billable service.
Q: What are some examples of medically necessary services?
A: Some examples include:
• Assessing a student for an acute exacerbation of asthma and providing necessary interventions to improve breathing
• Assessing a student for an allergic reaction and providing medically necessary interventions to stop the reaction
Nursing services must meet the level of being medically necessary as defined in ND Administrative Code 75-02-02-03.2(10).
Contact
Medical Services
600 East Boulevard Ave
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov
Policy Updates
January 2026
- School-Based Services
- IEP, Non-IEP, covered an non-covered services clarified and updated.
- Non-covered services
- Added clarifications
- FAQs
- Section added