Updated: April 2026
Purpose
ND Medicaid covers services provided by enrolled Rural Health Clinics (RHCs) that are certificated by the Center for Medicare and Medicaid Services (CMS).
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.
RHC services can be provided by the following enrolled providers as allowed by their scope of their licensure.
A medical encounter may occur with the following practitioners:
- Physician
- Physician Assistant
- Nurse Midwife
- Visiting Nurse
- Nurse Practitioner
A behavioral health encounter may occur with the following practitioners:
- Clinical (Licensed) Psychologist
- Licensed Clinical Social Worker
- Licensed Master Social Worker
- Licensed Professional Counselor
- Licensed Professional Clinical Counselor
- Licensed Marriage and Family Therapist
- Licensed Addiction Counselor
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.
Payment to RHCs for covered services furnished to members is an all-inclusive rate for each encounter. Encounter in this policy is defined as a face-to-face or synchronous telehealth visit with the member during which a qualifying RHC service is rendered.
Each encounter includes covered services by a medical professional plus related services and supplies.
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 encounter, except when the following condition exists:
- After the first encounter, the member suffers an illness or injury requiring additional diagnosis or treatment.
Immunizations
Refer to the Immunizations policy for additional information on immunizations and immunization administration.
Immunizations administered in conjunction with a medical encounter are considered incident to the medical encounter and neither the vaccine nor the vaccine 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 (vaccine administration) along with the appropriate CPT® code.
- The claim must include Revenue Code 0636 (Drugs requiring detailed coding) and the appropriate CPT for the vaccine.
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 immunization. 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 Revenue Code 0636 (Drugs requiring detailed coding) and the appropriate CPT® code.
See Telehealth policy for additional information on services rendered via telehealth.
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.
Effective July 1, 2024, all RHCs 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.
A separate claim line with each appropriate revenue code and procedure code along with the date of service. The provider must submit each claim line with their usual charges for the services.
Make sure to use the appropriate revenue code. For example, do not submit a vaccine administration code with revenue code 0521. Vaccine administration must be submitted with revenue code 0771.
When submitting claims for more than one encounter for a member on the same day at a single location, the RHC must bill the correct revenue code for each encounter and include the appropriate diagnosis codes (when applicable) on each claim.
Modifier 59 must be reported when billing for a member who suffers an illness or injury requiring additional diagnosis or treatment after the member’s first encounter on the same day. Modifier 59 must be reported on the revenue code 052X claim line.
Do not submit modifier 59 when the member sees more than one health professional or multiple services with the same health professionals on the same day.
Claims must be submitted using the following Revenue Codes when billing for:
- Revenue Code 0521 - Clinic Visit by Member to RHC/FQHC
- Revenue Code 0522 - Home Visit by RHC/FQHC Practitioner
- Revenue Code 0524 - Visit by RHC/FQHC practitioner to a member in a covered Part A stay at a skilled nursing facility (SNF)
- Revenue Code 0525 - Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay) of NF or ICF/MR or other residential facility
Claim Form
RHC services must be billed using the UB 04 claim form or 837i. Detailed claim instructions available on ND Medicaid Provider Guidelines, Policies & Manual webpage.
References
Related Policies
Contact
Medical Services
600 East Boulevard Ave
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov
Policy Updates
April 2026
- Claim form information updated.
- ADA updates added throughout document.