School-Based Services

Updated: July 2026

Purpose

Medicaid is a jointly funded federal-state health coverage program for individuals with low income and/or disabilities. Medicaid provides support for health care services delivered in schools and helps schools reduce health care-related costs.

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.

School-based services can be provided by the following enrolled providers as allowed by their scope of their licensure: 

  • Physical therapists;
  • Occupational therapists;
  • Speech language therapists;
  • Registered nurses and licensed practical nurses;
  • Licensed clinical social workers;
  • Licensed master social workers
  • Licensed professional counselors; and 
  • School psychologists. Enrolled school psychologists must have a specialist degree in school psychology from a national association of school psychology-accredited institution or have achieved the national certification of school psychologist. 

School-based providers who may enroll as behavioral health rehabilitative service providers include;

  • Licensed baccalaureate social workers;
  • Licensed associate professional counselors;
  • Behavior modification specialists;
  • Behavior analysts; and 
  • Mental health technicians. 

Please see the Behavioral Health Rehabilitative Services policy for eligibility requirements, allowed services, provider qualifications, and supervision requirements.

Provider Enrollment

To ensure correct accounting of funding for services, if a school employs practitioners who render both Individualized Education Program (IEP) services and non-IEP services, the school must obtain two separate enrollment records for billing and reimbursement. 

  • IEP services 
    • Provider Type 025 – Agencies 
    • Specialty Code 397 
    • Taxonomy Code – 251300000X
  • Non-IEP services
    • Provider Type 026 – Ambulatory Health Care Facilities
    • Specialty Code 504 
    • Taxonomy Code – 193200000X

Public school districts, private schools, and regional education associations may enroll to provide and bill non-IEP services. Only public-school districts or special education units may bill for IEP services. 

Schools may bill ND Medicaid for health-related services provided to students with Individualized Education Plans (IEPs) and students without IEPs. There are differences between billing for services provided under IEPs and those provided outside of IEPs. This policy explains those differences.

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.

This can be done in one of three ways:

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.

School Medicaid Requirements (IEP and Non-IEP)

All students must be enrolled in Medicaid on the date of service and:

  • Providers must be:
    • Enrolled with ND Medicaid on the date of service; 
    • Employed by or contracted through the school; and
    • Qualified/licensed to provide services within the scope of their practice.
  • Services must be:
    • Covered under the ND Medicaid Plan (see Medicaid provider policies for covered services);
    • Medically necessary;
    • Provided directly to the student;
    • Medical, not educational or instructional; and
    • Billed under separate enrollment records for IEP, non-IEP, and 1915(i) services.

ND Medicaid is responsible for paying medically necessary health service costs of Medicaid-eligible students in the student’s IEP per the Individuals with Disabilities Education Act (IDEA). ND Medicaid will pay schools for services based on submitted claims. 

IEP Medicaid Services Billed by Schools 

IEP Requirements

Services must be: 

  • Authorized or prescribed and outlined in the student’s IEP;
  • Updated on the student’s IEP as services start or stop; 
  • Billed by a public school or special education unit; and
  • Medically necessary, as defined in N.D. Admin. Code § 75-02-02-03.2(10):
    • Medical or remedial services or supplies required for treatment of illness, injury, diseased condition, or impairment; 
    • Consistent with the recipient's diagnosis or symptoms;
    • Appropriate according to generally accepted standards of medical practice; 
    • Not provided only as a convenience to the recipient (student) or provider; 
    • Not investigational, experimental, or unproven; clinically appropriate in terms of scope, duration, intensity, and site; and 
    • Provided at the most appropriate level of service that is safe and effective. 

Other service requirements include:

  • Nursing services require a written order documenting medical necessity;
  • Other health-related services must be authorized by an other licensed provider (OLP) operating within their scope of practice;
  • A licensed practitioner from the IEP team may act as the ordering/referring provider for billing purposes. This includes OT, PT and SLPs.

Covered IEP Services include:

  • Therapies: 
  • Audiology; 
  • Behavioral Health Services including behavioral health rehabilitative services. 
    • The student must meet the eligibility requirements for behavioral health rehabilitative services, including having a medical diagnosis, and all other behavioral health rehabilitative services guidelines apply. See Behavioral Health Rehabilitative Services policy for more information.
  • Nursing Services that support the students’ needs to access free appropriate public education (FAPE) provided by licensed practical (LPN) or registered nurses (RN). The following nursing services can only be billed if the services are medically necessary and are related to goals on an IEP, 504 or Individualized Health plan (IHP). These services include:
    • T1000 (IEP Only)
      • Private duty/independent nursing service(s) – licensed, up to 15 minutes per unit, with a maximum of 32 units per day for students with complex medical needs.
      • Modifiers must be used to differentiate if an RN (TD) or LPN (TE) delivers the services.
    • T1001 (IEP, 504, or Individual Health Plan (IHP))
      • Nursing assessment or evaluation
    • T1002 (IEP, 504, or IHP)
      • RN services, up to 15 minutes
    • T1003 (IEP, 504, or IHP)
      • LPN services, up to15 minutes
  • Written orders can be from a physician, nurse practitioner, or physician assistant.
  • Transportation from school to IEP services provided at an offsite location, and transportation back to school. Inclusion of the service in the student’s IEP is mandatory; 
  • Applied behavior analysis (ABA) for students with Autism Spectrum Disorder (see Medicaid Applied Behavior Analysis policy for additional coverage and service authorization requirements). Note: Service authorization must be received and approved prior to services being rendered; 
  • Initial Evaluations, Reevaluations, and Assessments conducted for the sole purpose of identifying the health-related needs for implementation of a student’s IEP or Individualized Family Service Plan (IFSP) for continuation of that plan:
    • Assessments must be conducted by licensed and Medicaid-enrolled professionals working within their scope of practice.
    • Assessments are covered even when:
      • the service is not added to an IEP or IFSP; and
      • an IEP or IFSP is not implemented.
  • If an evaluation occurs over multiple days, only one evaluation claim may be submitted with the date of service as the date the evaluation is initiated.

 

Covered Non-IEP Services

Non-IEP services include those provided pursuant to a 504 plan (services that are not already part of an IEP), student health plan, nursing plan, or physician, physician’s assistant or nurse practitioner’s order. Services that are otherwise covered by ND Medicaid may be rendered in a school. Services are subject to the same service authorization requirements and limits as (non-IEP) services rendered outside of the school. 

Non-IEP services include services covered under the Medicaid State Plan. Examples of potential non-IEP services include Behavioral Health Rehabilitative services, immunizations, and well-child checks.

Non-IEP Requirements

Third Party Liability (TPL) requirements apply if there is a liable third party. Medicaid is not the primary payer for non-IEP services (excluding 1915(i) services and supports). If the student has another source of health coverage or there is another responsible party, schools must bill the other responsible party(ies) before billing ND Medicaid.

Practitioners not employed by the school who render services to Medicaid-eligible students in the school must have approval from the school before rendering services.

Concurrent IEP and Non-IEP Services

Medicaid will pay all eligible providers delivering medically necessary services to Medicaid recipients. A school district or special education unit may bill Medicaid for IEP-related health services provided to a recipient who also receives non-IEP related rehabilitative services from a non-school district provider type, such as a rehab agency or outpatient hospital. IEP-related services and non-IEP related services provided on the same day may be billed so long as they are not duplicative, meaning that both services are the same in scope and nature. Documentation by each provider must reflect medical necessity for concurrent care by both providers.

Medicaid Administrative Claiming (MAC)

The MAC program allows school districts, special education units (SEUs) and regional education associations (REAs) to be reimbursed for some of their costs associated with school-based health and outreach activities which are not billable as direct services under the Medicaid fee-for-service benefit plan. The school-based health and outreach activities funded under MAC include: 

  • Referrals of students/families for Medicaid eligibility determinations; 
  • Providing healthcare information; 
  • Coordination and monitoring of health services for students; and 
  • Interagency coordination of services. 

MAC activities cannot duplicate direct service reimbursement. 

School districts, SEUs and REAs participating in the MAC program must meet certain requirements. The districts must:

  • Execute a Participation Agreement with North Dakota Medicaid;
  • Designate at least one employee to be the point of contact for the program;
  • Submit district staff and calendar information to ND Medicaid’s vendor; 
  • Participate in random moment time studies; and
  • Certify the funds reported for the administrative claim calculated by ND Medicaid’s vendor.

All participating school districts, SEUs and REAs will be included in the statewide sample for the administrative claiming program. MAC payments will be calculated by ND Medicaid’s vendor based on the random moment time studies.

MAC payments are the Federal share of funds paid for administrative services provided on behalf of Medicaid-eligible school recipients and their families. School districts, SEUs and REAs must certify the state matching funds for the MAC payments.

1915(i) Services and Supports

The 1915(i) program allows Medicaid to pay for home and community-based services to support members with behavioral health conditions including mental illness, substance use disorders, and/or brain injury. 

1915(i) services and supports cannot be written into an IEP. They are considered non-IEP services. Medicaid is the primary payer for these services so third-party liability requirements do not apply. 

Students can receive 1915(i) services separately from an IEP. Please see the 1915(i) webpage. 

Telehealth

Health Services billed by schools can be delivered via telehealth; however, no originating site fee is allowed. See Telehealth policy for additional information.

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.

IEP Services 

Non-Covered IEP Services include:

  • Services provided that are not documented in the Medicaid-eligible student’s IEP;
  • Services not authorized by the appropriate authorization or written order;
  • Services that are not provided directly to the student such as attendance at staff meetings, IEP meetings, staff supervision, member screening, development and use of instructional text and treatment materials;
  • Communications between the provider and student that are not face-to-face;
  • Transportation to and from home to school;
  • Population screenings such as lice checks;
  • Services considered experimental or investigational;
  • Services considered educational or instructional in nature; and 
  • Medication administration.

 

Non-IEP Services 

Non-Covered Non-IEP Services include:

  • Services rendered without the appropriate service authorization;
  • Services that exceed Medicaid limitations; 
  • Services authorized or prescribed in the Medicaid eligible student’s IEP;
  • Communications between the provider and Medicaid member that do not maintain actual visual contact, unless allowed as a telehealth audio-only service;
  • Transportation to and from home to school;
  • Services considered experimental or investigational;
  • Services considered educational or instructional in nature; and
  • Administration of prescriptions and over-the-counter medications.

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. 

Documentation requirements for school-based services includes: 

  • Student’s Plan of Care (IEP, 504 Plan, other);
  • Prior authorizations;
  • Student’s medical record;
  • Prescriptions/referrals for IEP services;
  • Documentation of the service performed on the date of service, including notes signed and dated by the provider and support for the time spent rendering a service for all time-based codes including:
    • Start and stop time is recommended but total time spent with the member providing a service is acceptable. 
  • Documentation regarding where the service was provided and who provided the service;
  • School attendance records for the date of service on the claim;
  • Transportation logs;
  • Payroll records associated with school personnel providing services (available upon request);
  • Copies of contracts with medical providers;
  • National Provider Identification (NPI); and
  • Health-related components of an IEP or IFSP assessment.

Please see the documentation section of the Provider Requirements policy.

IEP documentation requirements include:

  • Anticipated frequency, location, and duration of services and modifications. See 34 C.F.R. § 300.320(a)(7); and
  • Providers must know their responsibilities for implementation of the student’s IEP and specific accommodations, modifications, and supports that must be provided for the student according to the IEP. See 34 C.F.R. § 300.323(d)(2).

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. 

Claim Form

School-Based services must be billed using the CMS 1500 claim form or the 837p HIPPA compliant form. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.

Claim Requirements

Services rendered in a school must be billed with place of service (POS) 03 (school); unless the provider agency or practitioner leases space in the school, in which case POS 11 (office) must be billed.

To ensure correct accounting of funding for services, if a school employs practitioners who render both IEP services and non-IEP services, the school must obtain two separate enrollment records for billing and reimbursement. 

  • one for IEP services 
  • one for non-IEP services

Schools enrolling as non-IEP providers should add “non-IEP” to the end of their non-IEP provider enrollment names – e.g. Provider Name: Rancher Public School non-IEP. 

When billing for one code that is billed in units (i.e. 15 minutes) throughout a day, report the total amount of units on one claim line.

Definitions

School – for purposes of this policy, means a public school district or special education unit.

Third party liability – means there is a third party who is responsible for the health care expenses. This could be private health care coverage or a parent who is court-ordered to pay a child’s medical expenses.

References

Related Policies

Frequently Asked Questions

Question (Q): What rules apply to a school’s receipt of Medicaid funds for school-based services?
Answer (A): Section 300.154(g) of IDEA Part B is one rule. There may be others. This section says that: 
1.    Proceeds from public benefits or insurance or private insurance will not be treated as program income for purposes of 2 CFR 200.307.
2.    If a public agency spends reimbursements from Federal funds (e.g., Medicaid) for services under this part, those funds will not be considered “State or local” funds for purposes of maintenance of effort provisions in §§300.163 and 300.203.

Q: How does the Medicaid Match work?
A: The Medicaid Match only applies to IEP services. Medicaid funding is a combination of federal and state dollars. State school aid payments are reduced by the state’s share of IEP service reimbursement. Schools keep the federal share of IEP service reimbursement. The match rate changes annually based on the Federal Matching Assistance Percentage (FMAP).
There is no Medicaid Match for 1915(i) and non-IEP services. Schools keep 100% of the reimbursement for those services.

Q: How do I handle a situation where a student is supposed to get 10 minutes of therapy a day, but the student is not able to get therapy on any given day/days (could be student or therapist absence or some other reason)? I make up those missed minutes on subsequent days or the next week.
A: Make sure that your documentation reflects the total number of minutes from the IEP that the student is supposed to get the service. Clearly document why the service was missed and when it was made up in your service notes.

Q: Will a student be able to receive both school-based IEP services and community-based Medicaid services?
A: Yes. IEP services necessary for the child to receive a free and appropriate public education (FAPE) should not limit services the student receives outside of school. Please notify ND Medicaid if you believe a student’s receipt of IEP services is negatively impacting their receipt of community-based services.

Q: My school employs practitioners who practice under the supervision of another licensed practitioner, such as an occupational therapy assistant (supervised by an occupational therapist). Can services provided by a practitioner who practices under supervision be billed through their supervising provider. 
A: Providers who are eligible to enroll with ND Medicaid must enroll and bill with their own NPI. This includes behavioral health providers who are eligible to enroll as a behavioral health rehabilitative services provider: Behavior Modification Specialists, Licensed Associate Professional Counselors, Licensed Master and Baccalaureate Social Workers, Mental Health Technicians, and Registered Nurses.

Other trainees and health care providers with limited licenses who practice under supervision, pursuant to the ND laws and regulations applicable to their profession, may be billed through the supervising provider’s NPI so long as the supervisee is not required to enroll and bill under their own NPI.

Services provided by a trainee or health care provider with a limited license practicing under supervision must be documented in medical records. Supervising practitioners must be responsible for satisfying all applicable state law and regulatory supervision requirements, and patient care provided by a supervisee. For more information, see the and Provider Enrollment policy.

Q: How does the Medicaid consent requirement work?
A: Any requirements for schools to obtain consent from parents relating to Medicaid are 
requirements of the Department of Education and not Medicaid/Center for. Medicare and Medicaid (CMS). Schools can look to §300.154 of IDEA for requirements related to Medicaid consent. There are also requirements related to consent to disclose personally identifiable information to a State entity for Medicaid billing under either FERPA (34 CFR part 99) or IDEA (34 CFR 300.622).

Q: I have a student who is transported to receive therapy at a non-school location per the student’s IEP. Is the transportation to that therapy service a separately billable service?
A: Yes. So long as the non-emergency medical transportation (NEMT) is in the student’s IEP and is delivered by a qualified provider in accordance with service requirements, it is a separately billable service.

Q: Is there a specific required form for students with 504 plans?
A: No. ND Medicaid does not require any specific form. Services must be medically necessary as described in this policy and services must be documented appropriately. See Provider Requirements policy for more information.

Q: What if the school doesn’t know or have a diagnosis, and we can't require parents to provide that?
A: To bill Medicaid, the provider must bill with a valid ICD-10 diagnosis. There is not a Medicaid requirement that the diagnosis come from a specific provider or a provider external to the school. The diagnosis must come from a provider operating within their medical scope of practice according to North Dakota Century and Administrative Code. Providers should consult with their licensing board if they have questions related to their scope of practice and ability to diagnose a medical condition.

Q: The state currently has specific IEP eligibility 'diagnoses' or qualifying disabilities, which are not medically labeled (for example DCD). Are we expected to give a medical diagnosis in order to bill?
A: The Department of Instruction (DPI) governs the requirement for IEPs and Free Appropriate Public Education. Those requirements are separate from Medicaid requirements for billable services. Medicaid requires a medical diagnosis and medical necessity for billing. Schools are not required to get a separate diagnosis if the diagnosis in the IEP demonstrates medical necessity for the service. Providers should use their clinical judgment to determine if billing for the service is appropriate according to Medicaid requirements or if additional documentation may be necessary to justify billing for the service.

Q: IEP teams need an Educational Disability Category, specific to ND DPI guidelines, to create an IEP.  MA is requiring a medical diagnosis, somewhere within the IWAR or IEP, to be able to bill - is this correct understanding?
A: Correct. Schools are not required to get a separate diagnosis if the diagnosis in the IEP demonstrates medical necessity for the service. Providers should use their clinical judgment to determine if billing for the service is appropriate according to Medicaid requirements or if additional documentation may be necessary to justify billing for the service.

Q: As a related service, OT is often tied to a writing or reading goal. How would this be billable as medically necessary? Even if the child qualifies for medically-based services, the goal is then educationally based specific to the skills the child needs to participate in school not the skills that are needed outside of the school setting. 
A: Handwriting therapy is considered educationally necessary when poor writing skills that are unrelated to a functional impairment prevent a student from accessing or progressing in their academic curriculum. It is considered medically necessary when it addresses a broader, functional impairment that impacts the student's overall health and daily living skills, regardless of the school setting.

Q: Does the medical necessity apply to IEP services also?
A: Yes.

Q: Am I understanding that we need ICD-10 codes on each billing service?
A: All submitted claims currently require an ICD-10 code to meet the definition of a claim. Claims submitted without a valid ICD-10 code will deny.

Q: In a group setting, do we need to track how many individual minutes are spent with each student, and then not bill if that time doesn't hit the 8-minute mark for each student 
A: For group therapy, you must have an individual note for each participant in the group including the focus of the group and how each individual responded to and/or participated in the group. Each individual person does not need to fully interact for 8 minutes. The therapy as a whole needs to meet the 8-minute rule.

Q: How do we bill speech-language evaluation time through observation or teacher consultation (without student present) by the speech language pathologist (SLP)? For example, do SLPs bill all the observation time of the student even if the SLP did not interact with the student? When 1:1 time is not possible, observations and checklists are used in the evaluation process. Observations and teacher interviews are listed in an Assessment Plan. 
A: Teacher interviews and creation of a plan without the student present are not billable services (unless you are using a code specific to file reviews or report writing such as 96130). Billable services must be face to face with a child. If observation is being done for the purposes of an assessment, then it must be clearly documented and tied back to the IEP or plan.

Q: We do not use ICD-10 codes as school psychologists. We use IDEA disability categories.
A: ND Medicaid currently requires an ICD-10 code on all claims to meet the definition of a claim. All submitted claims must have an ICD-10 code listed or they will automatically deny.

Q: This didn’t address evaluations. In school-based services, we don’t use medical criteria but do use educational criteria for autism, attention, ED, etc. We may be looking for qualifications for these.
A: If a claim is submitted to Medicaid from a school, it must meet Medicaid requirements for medical necessity.

Contact

Medical Services
600 East Boulevard Ave 
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov

Policy Updates

July 2025

  • Enrollment
    • Removed requirement for two separate NPIs.

January 2026

  • Covered Services 
    • Added service clarifications on billing evaluations.
  • FAQ
    • Added multiple FAQs
  • Format updated and clarifications added throughout the policy

April 2026

  • ADA updates made throughout the policy. 

July 2026

  • Covered Services
    • School Nursing services added including T1001, T1002, and T1003.