Sterilization and Hysterectomy

Updated: October 2026

Purpose

The policy outlines ND Medicaid coverage, payment, and federal requirements related to sterilization and hysterectomy procedures.

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.

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.

Elective Sterilizations

Providers that perform elective sterilization procedures for the primary purpose of permanent birth control must obtain consent prior to the procedure being performed.

ND Medicaid will cover elective sterilization procedures performed for permanent birth control if the member provides voluntary informed consent as outlined below.

Informed Consent Requirements

Providers must use the Federal Consent for Sterilization forms below; No other forms will be accepted.

Informed consent does not exist unless a consent form is completed voluntarily and meets all the following requirements.

The consent form must be signed and dated by the following:

The individual to be sterilized;
The interpreter, if one was provided;
The person who obtained the consent; and
The physician who performed the sterilization procedure.

Required Certifications

The person securing the consent must certify, by signing the consent form that:
- Before the individual to be sterilized signs the consent form, he or she is to be advised that no Federal benefits may be withdrawn because of the decision not to be sterilized;
- The requirements are explained for informed consent as set forth on the consent form; and
- To the best of his or her knowledge and belief, the individual to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized.
The physician performing the sterilization must certify, by signing the consent form, that:
- Shortly before the performance of sterilization, the individual to be sterilized was advised that no Federal benefits may be withdrawn because of the decision not to be sterilized;
- The requirements are explained for informed consent as set forth on the consent form; and
- To the best of his or her knowledge and belief, the individual appeared mentally competent and knowingly and voluntarily consented to be sterilized.

Except in the case of premature delivery or emergency abdominal surgery, the physician must further certify that at least 30 days have passed between the date of the individual's signature on the consent form and the date upon which the sterilization was performed.

In the case of premature delivery or emergency abdominal surgery performed within 30 days of consent, the physician must certify that the sterilization was performed less than 30 days, but not less than 72 hours after informed consent was obtained because of premature delivery or emergency abdominal surgery and:

In the case of premature delivery, must state the expected date of delivery; or
In the case of abdominal surgery, must describe the emergency.

If an interpreter is provided, the interpreter must certify that he or she translated the information and advice presented orally and read the consent form and explained its contents to the individual to be sterilized and that, to the best of the interpreter's knowledge and belief, the individual understood what the interpreter told him or her.

Failure to meet the above requirements will result in a denial of the sterilization claim(s) under the contractual obligation, and the member may not be billed.

Hysterectomy (Non-elective Sterilization)

ND Medicaid covers medically necessary hysterectomy procedures that are not for the sole purpose of sterilization when the following criteria have been met, and the SFN 614 has been completed.

SFN 614 – Physician Certification for Medically Necessary Hysterectomy and Member Acknowledgment of Sterility: English - PDF.

The person who secures the certification to perform the hysterectomy has informed the individual and her representative, if any, orally and in writing, that the hysterectomy will make her permanently incapable of reproducing; and the member or her representative, if any, has signed a written acknowledgment of receipt of that information.

If the member is already sterile at the time of the hysterectomy, the physician who performs the hysterectomy must certify in writing that the woman was already sterile, stating the cause of that sterility.

If the member requires a hysterectomy because of a life-threatening emergency, in which the physician determines that prior acknowledgment is not possible, the physician must certify in writing that the hysterectomy was performed under a life-threatening emergency situation in which he or she determined prior acknowledgment was not possible. He or she must also include a description of the nature of the emergency.

A representative/guardian must sign the form for a member who is not mentally competent. A member residing in an institution may sign the acknowledgment for themselves unless a court has found them incompetent.

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.

Sterilization is done via hysterectomy solely for the purpose of rendering an individual permanently incapable of reproducing;
Sterilization is done via hysterectomy, and there was more than one purpose for the procedure, but it would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing;
Sterilization procedures that are performed on mentally incompetent or institutionalized individuals;
Sterilization of an individual who has not reached his or her 21st birthday when the sterilization consent form is signed;
Sterilization when the consent form is not completed, is not accurate, is not signed, or is not legible;
Sterilization when the consent form was not signed 30 days or more prior to the surgery, unless it qualifies for one of the stated exceptions;
Sterilization when the consent form was signed more than 180 days prior to surgery; or
Procedures to reverse a previous sterilization.

Standards for Retroactive Eligibility

Sterilization consent form requirements cannot be met retroactively. Providers may want to complete a consent form and allow for the 30-day waiting period when individuals without financial resources or health care coverage request sterilization and indicate that they are considering application or have applied for ND Medicaid. An alternative approach would be to inform the individual, preferably in writing, that retroactive eligibility does not apply to sterilization procedures unless a consent form is signed and the 30-day waiting period is followed.

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.

Claim Form

Professional claims for Sterilization and Hysterectomy procedures must be submitted electronically via the 837P transaction. Institutional Elective Sterilization and Hysterectomy claims must be submitted electronically via the 837I transaction. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.

Claim Requirements

The Federal Consent for Sterilization or the Physician Certification for Medically Necessary Hysterectomy and Member Acknowledgement of Sterility (SFN 614) must be attached to the claim or received within 14 days, or the claim will be denied. Charges related to a sterilization procedure during hospitalization must be entered in the Notes/Remarks section on the Web Portal or the billing notes section for EDI transactions.

There are two forms that can be used for submission of claims attachments, SFN 177 or the MMIS Web Portal confirmation page. One of these documents needs to accompany the claims attachments. Review our Claims Attachments policy for further information

Definitions

Sterilization – any medical procedure, treatment, or operation for the purpose of rendering an individual permanently incapable of reproducing.

Hysterectomy – a medical procedure or operation for the purpose of removing the uterus.

Institutionalized individual – an individual who is:

involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility, including a mental hospital or other facility for the care and treatment of mental illness, or
confined, under a voluntary commitment, in a mental hospital or other facility for the care and treatment of mental illness.

References

Frequently Asked Questions

Question: Do oophorectomy or orchiectomy require a Federal Sterilization Consent to be obtained?

Answer: No, Oophorectomy and orchiectomy are medically necessary and are not performed for sterilization; therefore, these procedures do not fall under Medicaid written consent/sterilization requirements. Practitioners and facilities must follow standard consent and documentation practices, subject to audit and review if procedures are billed to ND Medicaid for eligible members.

Contact

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

Policy Updates

July 2026

Format updates and clarifications added throughout.

April 2026

Formatting changes made throughout the policy.

July 2026

Updated links to the HHS 687 Consent for Sterilization, including additional links to the version in Español and large print versions.
Grammatical corrections throughout the policy.
ADA updates made throughout the policy.