Orthodontics

Updated: January 2026

Purpose

ND Medicaid allows Orthodontics under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for members through the age of 20 with service authorization approval.

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.
Orthodontic services can be provided by the following enrolled providers as allowed by the scope of their licensure:

• Orthodontists; and
• Dentists.

Orthodontic screening services can be provided by the following enrolled providers as allowed by the scope of their licensure:

• Dentists North Dakota Administrative Code 20-02-01;
• Dental hygienists North Dakota Administrative Code 20-04 ;
• Dental assistants North Dakota Administrative Code 20-03-011;
• Registered nurses (RN) North Dakota Administrative Code 54-05-021; and
• Licensed Practical Nurse (LPN) North Dakota Administrative Code 54-05-011

For dental hygienists, dental assistants and nurses, orthodontic screening can be done after completing an orthodontia screening training. 

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 eligible to receive orthodontic services include:

• Members through age 20.

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. 

All orthodontic services require an EPSDT Comprehensive Orthodontic Screening (SFN 61) to determine eligibility for a referral to an orthodontist. If the initial EPSDT screening results in a referral to an orthodontist, the orthodontist will complete a second EPSDT Comprehensive Orthodontic Screening (SFN 61) and will then submit a service authorization for specific orthodontic services for review by the ND Medicaid Program dental consultant for medical necessity. At times, the EPSDT screening by the child’s dentist or public health screener will be done after the orthodontist’s screening.

The screening form must be completed in its entirety meeting the following requirements: 

• The form must be signed in ink or signed electronically by the screener/dentist and dated on the day the screening took place;
• ND Medicaid will not accept a stamped signature;
• The member’s Medicaid ID number must correspond with the member’s name; and
• The signed screening form must be current and no older than one year from the date the service authorization request is received by ND Medicaid.

Orthodontic services may be covered for members with the following:

• The presence of a cleft lip or cleft palate: 
  • Allows for an immediate referral to an orthodontist regardless of age with the following:
    • A completed SFN 61.
    • No points are needed. 
• Limited Orthodontia Treatment:
  • Members age 7-10;
  • Early treatment of developing malocclusions; or
  • Anterior crossbite, posterior crossbite, and ectopic (mal positioned) incisors.
• Comprehensive Orthodontia Treatment:
  • Members age 10-20; or
  • Improvement of craniofacial dysfunction and/or dentofacial abnormalities.

Service Authorization Requirements

Service authorizations are required for orthodontic services. The service authorization requires:

• The initial and the orthodontic provider’s EPSDT Comprehensive Orthodontic Screening (SFN 61):
  • Both screenings must be included with the service authorization.
• A narrative description of the medical need for orthodontics, including the member’s orthodontic index score (please note, the orthodontic index sets 20 points as the minimum necessary to be eligible for orthodontic treatment);
• Radiographs;
• Additional photos that support medical necessity; and
• Cephalometric films (when taken).

Orthodontist to orthodontist screening and referrals will be considered on a case-by-case basis. Dentist to dentist screening and referrals for practitioners within the same dental practice will be considered on a case-by-case basis. Should the screening and referral occur prior to the orthodontist referral, ND Medicaid will consider this on a case-by-case basis dependent on the timeframe of the screenings.

Additional documentation will be required when orthodontia treatment is needed upon completion of previous orthodontic treatment. Medicaid allows limited (D8020 or D8030) or comprehensive (D8090) orthodontia. These treatments are not considered Phase I/Phase II orthodontia. All service authorization requests for orthodontic care will be decided based on medical necessity on a case-by-case basis.

Noncovered Services

General Noncovered Services

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

Noncovered orthodontic treatment includes:

• Orthodontic treatment involving clear aligners;
• Non-bracketed orthodontia; and
• Fabrication and/or placement of aesthetic appliances.

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.

For members approved for orthodontic services, the following is required for claims processing when members have other insurance: 

• Explanation of Benefits from the third-party payor.
• Medicaid must billed in one lump sum on the date the brackets are placed.
• Pre-treatment estimate from the third-party payor.
• The pre-treatment estimate will only be required when the primary payor makes   incremental payments for the orthodontia.

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. 

Recipient liability may not be collected up front for orthodontic services.

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. 

It is recommended that orthodontia services be billed at the time brackets are placed. ND Medicaid will reimburse orthodontia at the current fee schedule amount. 

Orthodontic transfers require a service authorization. Orthodontic transfers may include members transferring in state, out of state, or from office to office. Payment may be prorated based upon the number of months of orthodontic treatment remaining. A new EPSDT screening form is not required for orthodontic transfers. The documentation submitted from the dental office will determine the prorated payment as it is based upon the treatment recommendations and months of remaining treatment.

The prorated calculation is based off the current fee schedule amount for comprehensive orthodontia on the date of service the claim was billed or the date that the braces are placed. Each orthodontic transfer case is unique, and the fees are determined based on the bracketing, initial consultation, removal, upper and lower retainers, and monthly adjustments.

Claim Form

EPSDT Screenings rendered in a local public health unit must be billed using the CMS 1500 claim form or 837p. 

EPSDT Screenings, Limited (D8020 and D8030) and Comprehensive (D8090) orthodontia rendered in a dental office must be billed using the ADA Dental claim form (837d). 

Claims must be billed electronically. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.

Claim Requirements

Registered nurses who complete the orthodontic screening must bill utilizing CPT® code T1002.  LPNs who complete the orthodontic screening must bill utilizing CPT® code T1003. The Orthodontic screening service may not be billed when completed in conjunction with a ND Medicaid EPSDT wellness visit. CPT® code S0302 includes payment for an orthodontic screening. 

The orthodontia screening may be billed in conjunction with other covered services when performed at the same dental visit. Dentists who complete this screening must bill utilizing CDT® code D8660. 

Definitions

EPSDT:

• Early – Assessing and identifying problems early
• Periodic – Checking children's health at periodic, age-appropriate intervals
• Screening – Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
• Diagnostic – Performing diagnostic tests to follow up when a risk is identified, and
• Treatment – Control, correct or reduce health problems found.

Limited – orthodontic treatment of the transition or adolescent dentition

Comprehensive – orthodontic treatment of the adult dentition

References

• North Dakota Administrative Code
• North Dakota Century Code
• Code of Federal Regulations

Related Policies

• Preventive Servies and Chronic Disease Management and Early and Periodic Screening, Diagnostic and Treatment (EPSDT) policy

Frequently Asked Questions

Question (Q): Can I do an orthodontic screening in addition to an EPSDT screening? 
Answer (A): No, this service is included in the EPSDT screening.

Q: Do I need to use the most up to date orthodontic screening form? 
A: Yes.

Q: Can I bill for Phase I and Phase II treatment?
A. Medicaid covers limited (D8020, D8030) and comprehensive (D8090) treatment. Medicaid does not cover D8070 or D8080 as Phase I / Phase II treatment.

Q: Does Medicaid cover non-bracketed orthodontics? 
A: No. Medicaid covers only fixed, bracketed orthodontia.

Contact

EPSDT Provider Contact
Phone: (701) 328-2014, option 2
Email: dhsmedicaidquality@nd.gov

EPSDT Member Contact
Phone: (701) 328-2014, option 1
Email: dhsmedicaidquality@nd.gov

Service Authorizations
Email: dhsserviceauth@nd.gov
 

Policy Updates

January 2026

• Policy created.

May 2026

• ADA updates made throughout the policy.