Updated: April 2026
Purpose
ND Medicaid covers services provided by Psychiatric Residential Treatment Facilities (PRTFs) that are licensed and enrolled with ND Medicaid.
Certificate of Need
ND Medicaid will only cover PRTF services if the member meets certificate of need (CON) criteria. The admitting facility must complete an admission review with ND Medicaid’s contractor to assure the child’s cares and conditions meet North Dakota’s CON criteria.
Additional information and CON forms are available in the Under 21 Psychiatric Providers ND Children’s Treatment Services (CTS) Manual.
Rates for In-State PRTFs
The rate established for in-state PRTFs is all-inclusive for routine services. Routine services include supplies, therapies, personal supplies, equipment, transportation, and non- legend drugs. Separate billings for these items will not be paid. Enter only the room and board charges. Do not enter ancillary charges.
Rates for Out-of-State PRTFs
The rate for out-of-state PRTFs is based on the rate for comparable services established by the Medicaid agency in the state where the facility is located.
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.
Claims must be submitted to ND Medicaid using the following Revenue Codes when billing for:
- Revenue Code 0110 – In-House Medicaid Days
- Revenue Code 0182 – Noncovered Leave Days
- Revenue Code 0183 – Leave Days
- Revenue Code 0185 – Hospital Leave Days
The patient must be in the facility at 11:59pm on the day(s) coded for reimbursement.
Leave days are noncovered days.
ND Medicaid will cover a maximum of 15 days per occurrence for hospital leave. A PRTF may not bill for hospital leave days if it is known that the member will not return to the facility.
ND Medicaid will cover a maximum of 15 days per certification of need period for therapeutic leave. Prior authorization is necessary for additional days beyond the 15 - day certification of need period. Each occurrence of therapeutic leave must be documented in the electronic health record within 72 hours of the youth returning to the facility. Each documented therapeutic leave occurrence within the 90-day period must be included with the request for additional therapeutic leave days. Documentation must include progress notes detailing the utilized fifteen days of therapeutic leave and plan for additional therapeutic leave days, including specific dates and times they have been utilized and are planning to be utilized. Documentation must also include rationale related to continued PRTF placement with therapeutic leave days vs. planned discharge prior to the end of the ninety-day approval period.
A facility must submit a claim for every month a member is in the facility, even if insurance has paid for the services. This allows the system to apply recipient liability towards other claims. The claim should be submitted immediately after the month is over. Do not bill more than one calendar month per claim.
The number of units billed must include the date of discharge or death.
PRTF Transfer
Psychiatric Residential Treatment Facilities may transfer youth to another facility at the same level of care if the secondary facility is deemed a better environment for the youth. The CON is allowed to transfer to another PRTF if the original admitting PRTF transfers a youth to another PRTF within the first 45 days of admission. After 45 days, the CON may not be transferred, and a new non-emergent assessment would need to take place.
Policy Updates
May 2025
- Billing Guidelines
- Added clarification on when a day can be coded for reimbursement.
December 2025
- Billing Guidelines
- Updates on therapeutic leave days limit.
April 2026
- Reimbursement
- Added revenue code 0183 for noncovered leave days.
- Formatting changes throughout.