Updated: April 2026
Purpose
ND Medicaid covers transplants for members who have been evaluated by a transplant program and determined to be qualified for the transplant.
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.
Transplant services can be provided by the following enrolled providers as allowed by their scope of their licensure:
- Medicare Approved Transplant Center
A transplant program is defined as a component within a transplant hospital that provides transplantation of a particular type of organ to include heart, lung, liver, kidney, pancreas or intestine.
Transplants must occur in a center that has a Medicare provider agreement and comply with all Medicare requirements for organ transplants.
If Medicare has not designated a certified center, the transplant must be performed by a program that is participating with the Organ Procurement and Transplantation Network (OPTN) for the specific organ being transplanted. More information can be found on the CMS Transplant webpage.
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.
Transplant Covered Services
ND Medicaid transplant coverage includes medically necessary transplants and related services, including:
- Transplant evaluation,
- Member surgery;
- Donor surgery, including:
- Donor’s physician charges;
- Donor’s hospital charges; and
- Donor’s laboratory charges
- Cadaveric expenses,
- Tissue typing, and
- Searches and matches.
Procedure must be performed in order to prolong life, maintain, or improve quality of life, and must be performed using a human organ and be FDA approved.
Service Authorization Requirements
Service authorization is required for transplants that occur outside of North Dakota. Providers must submit Request for Service Authorization for Out of State Services (SFN 769) and supporting medical documentation.
A referral from an enrolled in-state Medicaid practitioner must be made for the member to be evaluated at an out of state transplant facility. After the out of state transplant facility completes its evaluation of the member and determines the member is a qualified candidate for the transplant, an enrolled Medicaid practitioner must make a referral for the transplant procedure and if being done outside of North Dakota, request authorization from ND Medicaid using the Request for Service Authorization for Out-of-State Services (SFN 769) and supporting medical documentation.
Each out-of-state after care appointment requires authorization using Request for Service Authorization for Out-of-State Services SFN 769 and supporting medical documentation. Refer to the Out of State Services policy for more information.
Noncovered Services
General Noncovered Services
The Noncovered Services Policy contains a general list of services that are not covered by North Dakota Medicaid.
ND Medicaid does not cover costs associated with organ removal from a Medicaid-eligible member living donor provided to another individual. Costs in these situations are the responsibility of the entity covering the organ transplant surgery. Other noncovered services include non-human organs such as animals.
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
Transplant services must be billed using the appropriate claim form or electronic transaction associated with the provider delivering services. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.
Claim Requirements
Donor Expenses
Covered services related to the donor must be billed under the member’s North Dakota Medicaid ID number.
Definitions
Organs – include heart, lungs, liver, pancreas, kidneys, multi-visceral and intestines.
Tissues – include corneas, skin, veins, heart valves, tendons, ligaments, and bones.
Stem Cell/Bone Marrow – includes autologous stem cell/bone marrow, allogeneic stem cell/bone marrow, and umbilical cord blood transplants.
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
- ADA updates made throughout the document.