Updated: April 2026
Purpose
Service authorizations (SA) are required for certain procedures, services, and items before being initiated, supplied, or performed. Failure to obtain a required SA will result in denial of the service or supply. Services or supplies paid without an approved SA are subject to recoupment.
Service Authorization Requirements
The Procedure Code Look-up Tool can be used to identify if a procedure code is covered by ND Medicaid along with specific service authorization requirements.
Service Authorizations are:
- Service, supply, provider, and date(s)-specific;
- Generally considered non-transferrable:
- A member can request to have an existing SA transferred to a different provider for good cause (e.g. moving). Members can do this by having the new provider submit a prior authorization with notes referencing the member’s current approval. When approved for a new provider, the previous provider’s SA will be end dated.
- Only modifiable by a written request from the provider. Modifications occur at the discretion of ND Medicaid.
- Web-based SAs must be resubmitted. They cannot be altered online.
Service Authorization Submission
Service authorization forms can be found online and contain directions for proper submission. For Durable Medical Equipment Service Authorizations, please see these instructions for submitting through the MMIS Web Portal.
ND Medicaid considers timely, retroactive, revision, or extension SA requests if all required forms and supporting information are submitted. Incomplete submissions will be returned or denied.
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.
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 (seven) years after the last date the claim was paid or denied. Providers must follow the documentation requirements in the Provider Requirements Policy.
Before submitting SA documentation, please:
- Ensure forms are complete and accurate;
- Include relevant information to support the SA. Highlighting documentation that specifically supports the SA’s medical necessity will expedite the review process;
- Add match requested service date(s) on all forms and documents;
- Add order/referral dates related to the SA requested dates.;
- Provide medical documentation, including medical records, to support medical necessity; and
- Include any other documentation required by ND Medicaid as listed in the service authorization criteria.
Requests not meeting these criteria may be returned, denied, or rejected as incomplete.
Providers may include letters or narrative with their request for service authorization; however, information supplied in a letter or narrative does not supplant the need for documentation supporting medical necessity in the medical record.
Retroactive Service Authorizations
Retroactive service authorizations may be submitted for consideration up to 90 days after the initial date of service with good cause for the delayed SA request (i.e., urgent/emergent medical conditions, retrospective eligibility). Retroactive requests should not be used on a routine basis. Providers must include documentation supporting good cause in their request for consideration of a retroactive service authorization.
Retroactive authorization requests are reviewed and decided internally on a case-by-case basis.
Resubmissions
Re-submissions require updated dates, documentation, and orders so they are current and complete. ND Medicaid does not keep documentation from earlier submissions. Decisions will be based on the most recent date of submission.
Denied SA Requests
ND Medicaid includes an explanation of the reason for denial as well as instructions for Medicaid members to appeal within 30 days. Provider may resubmit with new medical records or documentation at any time.
Reconsideration/Appeal
Within 30 days of a denied service authorization, a member may request reconsideration by contacting their provider and asking them to submit additional written information regarding the medical need for a service to ND Medicaid. ND Medicaid will review the request, decide, and notify both the member and provider of its decision.
Members may also request an appeal hearing if they believe ND Medicaid has made an error in denying the request for services. Requests for a hearing must be made by members in writing or by calling the Department of Health and Human Services (DHHS) Legal Advisory Unit within 30 days from the date of the denial. Hearing requests must be submitted to:
Department of Human Services
Attn: Appeals Supervisor
600 E Blvd Ave Dept 325
Bismarck ND 58505 0250
Phone: (701) 328-2311
Fax: (701) 328-2173
E-mail: dhslau@nd.gov
The purpose of the hearing is to give members an opportunity to show that Medicaid made an error in denying the service. The hearing will not be a venue to dispute established program limits. Sufficient medical evidence must be provided to show that a service is medically necessary, and that an error was made.
Definitions
Acentra Health – a contractor with ND Department of Health and Human Services to perform service authorization review of certain requests for services and supplies for members effective January 1, 2021. Acentra Health uses InterQual® criteria for determining medical necessity for services requiring authorization. More information can be found at https://nddhs.acentra.com/.
References
Contact
Medical Services
600 East Boulevard Ave
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov
Behavioral Health
Phone: (701) 328-7068
Fax: (701) 328-1544
Dental
Phone: (701) 328-4825
Fax: (701) 328-0350
Durable Medical Equipment
Phone: (701) 328-2764
Long Term Care, for Members Under 21
Inpatient Psychiatric Services and PRTFs
Phone: (701) 328-4864
Fax: (701) 328-1544
Non-Emergency Medical Transportation
Phone: (701) 328-4312
Optometry
Phone: (701) 328-4825
Fax: (701) 328-1544
Out of State Medical Care
Phone: (701) 328-2159
Fax: (701) 328-0376
Pharmacy
Phone: 800-755-2604
Fax: (701) 328-1544
Service Limits
Phone: (701) 328-4825
Fax: (701) 328-0377
Ascend (Long Term Care and Inpatient Psych
Services for Members Under 21
Phone: (877) 431-1388
1915(i) Services
Email: nd1915i@nd.gov
Policy Updates
January 2026
- Format changes and clarification added throughout the policy.
April 2026
- ADA updates made throughout the policy.