Provider Updates

Posted 12-26-2024

The Telehealth Policy and Telehealth Approved Services documents have been updated. Effective for dates of service on or after January 1, 2025, ND Medicaid will be accepting the new CPT© codes 98001-98015 for Synchronous Audio-Video Evaluation and Management Services. Providers should no longer submit CPT© 99202-99215 with POS 02 or 10; or modifiers GT or 95 on claims for members with ND Medicaid as the primary payer.

Posted 12-18-2024

The Codes Requiring Service Authorization spreadsheet has been updated.  

The following drugs have been added to require service authorization effective January 1, 2025.

The following genetic testing codes will require service authorization through Acentra effective January 1, 2025.

The following code has been removed from service authorization requirement effective 12/31/2024.

Posted 12-11-2024

Diabetic Supply Coverage Updates

Diabetic supply coverage changes, effective January 1, 2025, are reflected in the 2025 Preferred Drug List.

Continuous Glucose Monitors (CGM):

• Dexcom will remain the sole preferred CGM.
  • Non-preferred Guardian CGM may be requested by providers through prior authorization. Members must meet CGM coverage criteria and have had a Medtronic insulin pump either longer than a year or purchased by another payer.
    • For new insulin pumps, if continuous loop is required, a pump that is compatible with Dexcom should be chosen.
• No other CGM will be covered.

Insulin Pumps:

• Omnipod coverage will expand to members with type 2 diabetes, using multiple daily injections of short and long-acting insulin, Humulin R U-500, or an insulin pump.

Test strips:

• Accu-Chek Guide test strips will be the only test strips covered.
• Contour and OneTouch test strips will no longer be covered.

Biosimilars

The following biosimilars are being managed. In some cases, the originator product is no longer preferred. Please visit the 2025 Preferred Drug List to see which products are preferred.

• Adalimumab
• Bevacizumab (This does not include bevacizumab billed with C9257 for ophthalmic use)
• Filgrastim
• Infliximab
• Pegfilgrastim
• Rituximab
• Tocilizumab
• Trastuzumab

Naloxone Standing Order

The statewide standing order for pharmacists to prescribe naloxone OTC for Medicaid members has been renewed for an additional year.

Pharmacy Prior Authorization (PA) Updates

Pharmacy PA updates, effective January 1, 2025, are reflected in the 2025 Preferred Drug List.

Cystic Fibrosis Tobramycin:

• Bethkis will no longer be preferred.
• Please transition members to generic Tobi now which does not require PA.

Growth Hormone:

• Norditropin and Genotropin will be preferred with clinical PA.
• Please transition members to either Norditropin now or Genotropin after January 1, 2025.
• Nutropin AQ is being discontinued and will no longer be preferred.

PCSK9 inhibitors:

• Praluent will no longer be preferred and will require a step through Repatha.
• Please transition members to Repatha now. 

Stimulants for ADHD:

• Jornay PM, Aptensio XR, and amphetamine non-solid dosage forms will require PA
• Members 5 and under will require PA.

Sumatriptan Nasal and Injectable:

• Requires PA with step through oral or non-solid dosage form justification

Posted 12-09-2024

Effective for dates of service on and after January 1, 2025, ND Medicaid will begin editing professional and institutional claims against five additional Noridian Local Coverage Determinations (LCDs) and companion Billing and Coding articles.

• L33979 Benign Skin Lesion Removal
• L37549 Chest X-ray
• L39242 Epidural Steroid Injections for Pain Management
• L34076 Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma
• L34040 Polysomnography and Other Sleep Studies

The following local and national coverage determinations have been in place for claims editing since October 2023.

• Noridian Local Coverage Determinations (LCDs)
  • L35172 Botulinum Toxin Types A and B
  • L35175 MRI and CT scans of the Head and Neck
  • L34051 Vitamin D Assay Testing
  • L37281 Lumbar MRI
  • L36707 Lab: Controlled Substance Monitoring and Drugs of Abuse Testing
  • L37283 Electrocardiograms
  • L36700 Serum Magnesium
  • L36094 Lab: Flow Cytometry
  • L34038 B-type Natriuretic Peptide (BNP) Testing
  • L38904 Wound and Ulcer Care
  • L34074 Immune Globulin Intravenous (IVIg)
• CMS National Coverage Determinations (NCDs)
  • 190.12 Urine Culture, Bacterial
  • 190.15 Blood Counts
  • 190.16 Partial Thromboplastin Time (PTT)
  • 190.17 Prothrombin Time (PT)
  • 190.18 Serum Iron Studies
  • 190.21 Glycated Hemoglobin / Glycated Protein
  • 190.22 Thyroid Testing
  • 190.23 Lipid Testing
  • 190.27 Human Chorionic Gonadotropin

Posted 12-04-2024

The Codes Requiring Service Authorization spreadsheet has been updated.  

The following drugs will require service authorization effective January 1, 2025.

Service authorization will be removed for the following drug effective December 31, 2024.

Posted 11-05-2024

New Electronic Visit Verification (EVV) Policy & FAQ Document

A new policy affecting providers who use EVV takes effect Nov. 1, 2024. EVV has been required for some providers in North Dakota since 2021, but an official policy with specific requirements is new. All providers using EVV must follow the new standards for any EVV required services delivered starting Nov. 1, 2024.

What does the new policy say?
Some of the information has already been released in other formats, documents or on the North Dakota Health and Human Services (HHS) website; the policy combines that information in one document. The rest of the policy adds clear guidelines to providers on the requirements they must follow to remain compliant with federal and state standards.

What are the major sections in the policy?

• Definitions
• Programs subject to EVV
• Service types requiring an in-home visit
• Providers subject to EVV
• Service settings not subject to EVV
• Live-in providers
• Required EVV data
• Individuals receiving care - noncompliance penalties
• Signature verification
• Home and Community-Based Services (HCBS) subject to EVV
• Self-directed EVV supports
• Open EVV model
• Data collection methods for EVV data (Therap)
• Approval requirements
• Manual corrections of EVV visit (check in/check out) data
• Manual entry/correction/exception reason codes and  descriptions
• Documentation requirements
• Rounding rules used to calculate units EVV data collection and  examples
• Overnight visit requirements
• Common claim denial reason codes
• Noncompliance
• Reporting fraud, waste and abuse
• Legal authority

What is the most important thing to know?
Anyone that provides EVV required services needs to read this policy and follow these standards. The noncompliance section is extremely important to read, understand and follow.

Where do I find the updated EVV Fact & Question (FAQ) document?
You can find an updated document on the HHS website.

What types of providers must follow this policy?
EVV affects many different kinds of providers and programs. The EVV policy includes information for the following provider types that have to follow the standards.

• Agency and Individual Qualified Service Providers (QSPs)
• Licensed Developmental Disabilities (DD) Providers
• Children’s Medically Fragile, Autism Spectrum, Children’s Hospice respite and In-home support providers
• Self-Directed Providers
• Medicaid 1915(i) Respite Providers
• Home Health Agencies
• Traditional Individuals with Intellectual Disability/Developmental Disabilities (IID/DD) HCBS Waiver Self-Directed In-Home Support and Respite Providers

Who do I contact if I have questions?

• Therap technical assistance: ndsupport@therapservices.net
• EVV billing questions:  Automated Payment Line 1-866-768-2435
• All other billing questions: Medicaid Call Center 1-877-328-7098, Choose option “0” when prompted for a pin
• See the HHS EVV System website
   

Posted 10-30-2024

Attention ND Medicaid Providers: We are excited to announce that Provider Enrollment will be offering two webinars on Wednesday, Nov. 20, to discuss important updates that have occurred and/or will be occurring in the near future.

A big highlight that will be covered is the changes that have been made to the Individual and Group Applications.

Sessions will be scheduled for an hour to leave time for discussion.

To register, click on one of the links below. You may call in to the meeting, but will still need to register for a session.

NOTE: These sessions are not specific to the Qualified Service Provider (QSP) enrollment process and not intended for QSPs.

Register: Nov. 20, 10 to 11 a.m. CT webinar
Register: Nov. 20, 1:30 to 2:30 p.m. CT webinar
 

Posted 10-14-2024

The Codes Requiring Service Authorization spreadsheet has been updated.  

Effective Oct. 31, 2024, the following drugs will no longer require service authorization.

Effective Nov. 1, 2024, the following drugs will require service authorization.

Posted 10-8-2024

The Health Tracks Comprehensive Orthodontic Screening Form (SFN 61) has been updated effective October 2024. The new updates include screener observations, dental caries and restorative needs, the date of the most recent dental exam, and parent/patient compliancy.

This form must be submitted in addition to the service authorization request, radiographs, photos, and a cephalometric film (when taken). The form must be completed in its entirety when submitting in addition to a service authorization. Previous form versions will be accepted through June 2025.

Posted 9-30-2024

The following Provider Guidelines, Manuals, and Policies have been updated for October 2024. New language appears between « » symbols throughout the individual policies.

• 1915(i) Medicaid State Plan Amendment
• Home Health and Private Duty Nursing
• Hospital Services
• Immunizations
• Indian Health Service and Tribal Health Programs
• Noncovered Medicaid Services
• Other Licensed Providers
• Provider Enrollment
• Provider Requirements (formerly Provider Information)
• School-Based Medicaid

And please note the following new/merged policies:

• Service Authorizations - NEW in October
• Preventive Services and Chronic Disease Management has been combined with Health Tracks under one policy titled "Preventive Services and Chronic Disease Management and Health Tracks"

Posted 9-20-2024

Effective Oct. 1, 2024, Acentra Health (formerly known as KEPRO) will be reviewing authorization requests for Genetic Testing Services. Services must be submitted directly to Acentra Health through the online Atrezzo portal. The Codes Requiring Service Authorization has been updated to reflect these changes.  

To register for an account, access the Acentra Health portal.  
Provider information and trainings are available online.

Providers may contact Acentra Health directly at ndumnurses@acentra.com for additional information or to submit questions. 

Posted 9-12-2024

Pharmacy prior authorization (PA) updates:

• Repatha no longer requires PA
• Pimecrolimus now requires PA
• Invokana and Invokamet now require PA

Delestrogen highest strength (200 MG/5 ML) has been discontinued

• Other strengths are still available
• Depo-estradiol is another preferred option without PA

Synagis coverage:

• Respiratory Syncytial Virus (RSV) Season defined as onset (1st of 2 consecutive weeks when percentage of polymerase chain reaction (PCR) tests positive for RSV is > 3% and offset (Last of 2 consecutive weeks when percentage of PCR tests positive for RSV is < 3%) as reported by The National Respiratory and Enteric Virus Surveillance System (NREVSS) Region 8 RSV Regional Trends
• North Dakota Medicaid will not pay for Synagis for the following patients
  • Infants eligible to receive Beyfortus through the Vaccine for Children (VFC) program
  • Infants who have received immunity through a maternal RSV vaccine and/or another monoclonal antibody for RSV prophylaxis during the current season

Posted 9-10-2024

The Codes Requiring Service Authorization spreadsheet has been updated.  Effective Oct. 1, 2024, the following drugs will require service authorization.

Posted 8-21-2024

The Immunization (Vaccine/Toxoids) policy has been updated to include the trivalent influenza vaccine codes for the 2024-2025 season.  

Posted 8-15-2024

The following policy is updated effective August 2024:

• Third Party Liability

Posted 8-5-2024

The following policies have been updated effective August 2024:

• Federally Qualified Health Centers
• Indian Health Service/Tribal Health Program
• Rural Health Clinic

New policy language appears within these symbols «   ». Please contact Policy Director Mandy Dendy with any questions or concerns.

Posted 7-24-2024

Timely Filing Extension Due to Change Healthcare Cyberattack

******The timely filing extension granted by the department will end on 7-25-2024*****

Due to the recent cyberattack on Change Healthcare, ND Medicaid will extend timely filing requirements for claims with dates of service on or after 09/21/2023. Claims must be submitted by either 07/25/2024 or the regular timely filing deadline, whichever is later.

If you are unable to submit claims electronically to the department, you may send them on paper or submit your claims via the MMIS Web Portal.

Posted 7-23-2024

Updated policies posted

The following provider policies have been updated on the Medicaid Provider Guidelines, Manuals, and Policies webpage.

Behavioral Health Rehabilitative Services

• Behavior Analysts are added as enrollable providers and certified Registered Behavior Technicians are recognized as Mental Health Technicians.

Other Licensed Providers (OLPs)

• School Psychologists are now Medicaid-enrollable providers.

School-Based Services

• Now includes listing of school-based provider types, including school psychologists, as well as an updated FAQ section.

New policy language appears within these symbols «   ». Please contact Policy Director Mandy Dendy with any questions or concerns about any of the above.

The Codes Requiring Service Authorization spreadsheet has been updated.  Effective July 2, 2024, the following drug requires service authorization.

Posted 7-15-2024

Acentra Health - Vendor for expanded post-payment provider reviews

Background: Acentra Health (formerly known as KEPRO) has been a vendor of the ND Medicaid program since 2021. Acentra processes certain service authorizations and completes retrospective reviews of inpatient and outpatient hospital claims.  

What’s Changing: Acentra is expanding post-payment provider reviews with new focus areas including emergency room visits, behavioral health services, applied behavioral analysis and evaluation and management services for members in nursing facilities.  

What to Expect: Your organization may be contacted by Acentra to request information about services you provided to ND Medicaid members. These requests are legitimate and are intended to inform more robust policies and guidance for providers.  

Live trainings will be offered July 23-25 and will also be available online for later viewing.

Register for the live provider trainings. Questions? Contact ndumnurses@acentra.com.

Attention Behavioral Health Rehabilitative Service Providers:

The Behavioral Health Rehabilitative Services policy has been updated per a state plan amendment with a July 1, 2024, effective date. We apologize for the delay in publishing an updated policy and sharing the update with you as well as any difficulties the delay may cause.

Changes to note:

• The skills restoration (H2014) and skills training (H2017) services have been combined into one service – skills training and integration. A blended rate has been established for this service and it will be billed under H2014. You’ll note the rate for this service is slightly lower its previous level. The reasoning for the service combination and blended rate is to ensure seamless service delivery. Skills restoration and training seem to, more often than not, be delivered as one service where a skill is taught and then practiced during the same working session. It didn’t seem to make sense to have these services separated and potentially delivered by different providers. The rate was adjusted to account for the inclusion of mental health technicians as providers who will assist with skills training and integration by practicing skills the member has been learning in their therapy programs.

The revised Behavioral Health Rehabilitative Services policy is online. Please note that deleted language is shown by strikethrough font and new language appears within these symbols «   ».

If you have billed any instances of H2017 with dates of service on or after July 1, 2024, please resubmit those as H2014.

Please contact Policy Director Mandy Dendy with any questions or concerns about any of the above.

Posted 7-1-2024

Fee Schedule Update – The fee schedules for dates of services July 1, 2024, have been posted to the website.

Provider rates will receive a 3.0% inflationary increase for the first year of the biennium in accordance with the legislative mandate.

Codes which are priced off a fee schedule have been adjusted with the 3.0% inflation increase accordingly. Codes which are priced using the Relative Value Unit (RVU) methodology have had the conversion factor adjusted. The adjustment of the conversion factor accounts for the implementation of the 2024 RVUs for dates of service on or after July 1, 2024.

Based on the previous calendar 12 month’s claims volume, the new relative value unit adjustments, and a 3.0% inflationary increase for the first year of the biennium, the resulting conversion factor effective for July 1, 2024 dates of service and after is $36.2591. The previous conversion factor was $35.6438. Based on the changes to the relative value units, some fees will increase while others may stay the same or decrease. In the aggregate, the providers whose claims are priced off the RVU methodology will see a 3.0% increase in their reimbursement.

The Ambulatory Surgical Center (ASC) conversion factor effective for July 1, 2024 dates of service and after is $31.15 based on the 3.0% inflation increase.

The Anesthesia conversion factor effective for July 1, 2024 dates of service and after is $26.01 based on the 3.0% inflation increase.

Posted 6-28-2024

Effective July 1, 2024, Acentra Health (formerly known as KEPRO) will be reviewing authorization requests for Home Health Services, Extended Home Health Services, and Private Duty Nursing Services. Services must be submitted directly to Acentra Health through the online Atrezzo portal.

Home Health Service authorization is required when it is medically necessary for the member to exceed the home health visit limitation of 50 visits in a year.

To register for an account, access the portal here: Atrezzo - Login (kepro.com). 
Provider information and trainings are available online.

Providers may contact Acentra Health directly at ndumnurses@kepro.com for additional information or to submit questions. 

Posted 6-27-2024

Beginning July 1, 2024, our Provider Enrollment Contact Center will have a new phone number and new hours of operation.

Provider enrollment specialists will be available to answer questions between the hours of 8 a.m.-5 p.m. CT Monday through Friday.

Provider enrollment can be reached at (877) 328-7098 (toll-free) or (701) 328-7098.

Posted 6-25-2024

Attention DME Providers - Effective July 1, 2024, the following Certificate of Medical Necessities (CMN) will no longer be required:

• SFN 729 – Oxygen
• SFN 782 – Osteogenic Bone Growth Stimulator
• SFN 782 – Enteral Nutrition
• SFN 524 – CPAP/BIPAP

Posted 6-19-2024

Timely Filing Extension Due to Change Healthcare Cyberattack

Due to the recent cyberattack on Change Healthcare, ND Medicaid will extend timely filing requirements for claims with dates of service on or after 09/21/2023. Claims must be submitted by either 07/25/2024 or the regular timely filing deadline, whichever is later.

If you are unable to submit claims electronically to the department, you may send them on paper or submit your claims via the MMIS Web Portal.

ND Medicaid will continue to monitor the situation and adjust timely filing requirements if needed.

Address to submit paper claims:
Medical Services Division
North Dakota Health and Human Services
600 E. Boulevard Ave., Dept. 325
Bismarck, ND 58505-0250

Questions? Contact our Provider Relations Call Center by calling (701) 328-7098, toll-free (877) 328-7098, 711 (TTY) or emailing mmisinfo@nd.gov.

Posted 6-11-2024

Starting on July 1, 2024, ND Medicaid will cover the Firesafe Cannula Valve.

Firesafe devices help reduce the risk of fires by isolating the oxygen flow and putting out a fire that may travel back along the oxygen delivery tubing. These valves are meant to be installed in the oxygen delivery tubing or at the interface with the oxygen supply equipment.

It's recommended that each oxygen delivery circuit have two Firesafe devices. The first should be placed near the oxygen supply source and the second near the patient.

Providers are required to submit claims for the Firesafe device using the Current Procedure Terminology (CPT) code E0700. Each valve is considered one unit and the cost for each unit is $6.80. The limit is two units every six months.

If you have any inquiries, contact Tammy Holm, durable medical administrator at tamholm@nd.gov or 701-328-2764.

Posted 6-7-2024

The Codes Requiring Service Authorization spreadsheet has been updated.  Effective July 1, 2024, the following drugs will require SA.

Posted 6-5-2024

The June 2024 Issue of our Provider Newsletter is now out! This newsletter includes information on new services added, updates to the preferred drug list, a new prior authorization web link, opportunities to add fluoride varnish to well-child or other child clinic visits, helping members apply for Medicaid, sharing our Member E-Newsletter with members, and more.

Subscribe to receive future newsletters by scrolling down to the middle of the page, entering your email address, and selecting your subscription preferences here. Select "Medicaid - Provider Updates" to get this newsletter.

Posted 6-5-2024

FQHC Billing Update

Beginning with dates of service July 1, 2024, all FQHCs 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.

Modifier 59 must be reported when billing for a member 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. Do not submit modifier 59 when the member has a medical visit and a behavioral health visit on the same day.

For dental encounters all services must be submitted with revenue code 0512.

RHC Billing Update

Beginning with dates of service 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.

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.

Posted 5-28-2024

The following changes are effective May 29, 2024. The full updated criteria can be found in the Preferred Drug List (PDL).

Diabetes Updates

• Novolog and insulin aspart require prior authorization (PA).
• Apidra (insulin glulisine) requires PA.
• Fiasp (insulin aspart) does not require PA but does require an electronic lookback for a 3-month supply of Humalog within the past 180 days in claim history.
• Ozempic, Rybelsus, and Bydureon Bcise are covered after a trial with Victoza with 2 other antihyperglycemic agents. In addition, Trulicity and Mounjaro require a trial of Ozempic with 2 other antihyperglycemic agents.
• Victoza is still covered without PA.

Other Updates

• Symbicort requires PA.
• Dexilant and Konvomep require PA.
• Ciprofloxacin/dexamethasone requires PA.

Posted 5-7-2024

Academic detailing

Academic Detailing meetings will be hosted by Acentra Health via Teams to provide information concerning ND Medicaid pharmacy initiatives and desired outcomes, including updates to the preferred drug list (PDL) and PA forms.

Information will be provided by Russell Moore (Medicaid Pharmacy Specialist - Acentra Health).

If you wish to receive emails regarding quarterly Academic Detailing meetings:

Email ndacademicdetailing@acentra.com

• Subject line: “Join Email List”
• Include your practice site or pharmacy information

Posted 4-30-2024

The ND Medicaid pharmacy prior authorization (PA) website has migrated to a new URL. Please save this link for the new landing page: https://ndmedicaid.acentra.com/

The above link replaces the previously used www.hidesigns.com/ndmedicaid. Redirection to the new landing page will occur on May 1, 2024.
 
This website hosts ND Medicaid’s preferred drug list (PDL) with coverage criteria, drug PA forms, Drug Use Review (DUR) Board information, and provider education material.

Updated direct links for other important pages are included below. You can also navigate to these pages through the drop-down menus at the top of the landing page.

• Preferred Drug List
• PA forms 
• Academic detailing

Posted 4-15-2024

Omnipod coverage is no longer restricted by age. Please visit the Preferred Drug List to view updated coverage criteria.

Posted 4-9-2024

The Codes Requiring Service Authorization spreadsheet has been updated.  The following drugs will require SA effective May 1, 2024.

Posted 4-8-2024

Timely Filing Extension Due to Change Healthcare Cyberattack

Due to the recent cyberattack on Change Healthcare, ND Medicaid will extend timely filing requirements for claims with dates of service on or after 09/21/2023. Claims must be submitted by either 06/25/2024 or the regular timely filing deadline, whichever is later.

If you are unable to submit claims electronically to the department, you may send them on paper or submit your claims via the MMIS Web Portal.

ND Medicaid will continue to monitor the situation and adjust timely filing requirements if needed.

Address to submit paper claims:
Medical Services Division
North Dakota Health and Human Services
600 E. Boulevard Ave., Dept. 325
Bismarck, ND 58505-0250

Questions? Contact our Provider Relations Call Center by calling (701) 328-7098, toll-free (877) 328-7098, 711 (TTY) or emailing mmisinfo@nd.gov.

Posted 4-3-2024

To reduce processing time, please verify your provider is not actively enrolled with North Dakota Medicaid before submitting a new online enrollment application in the MMIS portal. If a provider is actively enrolled, a new online application is not required.

You can search for actively enrolled providers by NPI or Name using the following links:

• Individuals by NPI: hhs.nd.gov/sites/www/files/documents/Taxonomy List Individual.pdf
• Groups by NPI: hhs.nd.gov/sites/www/files/documents/Taxonomy List Group.pdf
• Instructions on how to search by name (MMIS Web Portal): 

When a provider is actively enrolled with North Dakota Medicaid:

• To add an affiliation, submit the Affiliation Form (SFN 1330)
• To add a Taxonomy, submit the Add Taxonomy Form (SFN 1302)
• If the provider is inactive, submit a Reactivation Form Packet

Posted 3-27-2024

The Hearing Aid Policy has been updated for services on or after April 1, 2024.  Changes include:

• Coverage of binaural hearing aids for all ages
• Removal of the primary care documentation requirement

Posted 3-26-2024

The following Provider Guidelines, Manuals and Policies have been updated for April 2024.   New language appears between « » symbols throughout the individual policies.

• Behavioral Health Rehabilitative Services
• Chiropractic Services
• Codes Requiring Service Authorization
• Hospital Services
• Immunizations (Vaccine/Toxoids)
• Indian Health Services and Tribal Health Programs
• Non-Emergency Medical Transportation
• Occupational Therapy
• Physical Therapy
• Preventive Services and Chronic Disease Management
• Provider Information
• School-Based Services
• Sign and Oral Language Interpreter Services
• Speech-Language Services
• Substance Use Disorder Treatment Services
• Telehealth Approved Services
• Telehealth

Posted 3-18-2024

Update: Licensed Addiction Counselors (LACs) have been removed from this requirement, which was originally posted on January 25, 2024.

Medicare will begin covering and making payments for the services of marriage and family therapists (MFT), mental health counselors on January 1, 2024.  

For dually eligible beneficiaries (those enrolled in both Medicare and Medicaid) who receive Medicaid coverage of services furnished by MFTs or MHCs services furnished by hospital outpatient departments, community mental health centers (CMHC), rural health clinics (RHC), federally qualified health centers (FQHC), or opioid treatment programs (OTP), beginning on January 1, 2024, Medicare will become the primary payer for these services provided by Medicare-enrolled practitioners or providers.

What does this mean for Medicaid-enrolled licensed marriage and family therapists (LMFT), licensed addiction counselors (all levels), licensed professional counselors (LPC), or licensed professional clinical counselors (LPCC) providers?  If you are currently enrolled in Medicaid as an LMFT, LPC, or LPCC, you will need to submit your enrollment information to Medicare by January 31, 2024, to prevent any disruption in treatment and payment for dually eligible beneficiaries and payment of claims.    

MFTs and MHCs could begin submitting their Medicare enrollment applications after the CY 2024 PFS final rule was issued on November 2, 2023. The effective date of enrollment may be up to 30 days before the submission of the enrollment application to Medicare, but no earlier than January 1, 2024, which is the date the new benefits authorized by the CAA, 2023 take effect. Newly Medicare-enrolled LMFTs, LPCs, and LPCCs will not be granted an effective date earlier than January 1, 2024, and claims with dates of service before January 1, 2024, will not be payable by Medicare.

Claims submission instructions:

• If you are not yet enrolled with Medicare: submit your Medicare enrollment by Jan. 31, 2024, per the instructions linked below. Continue to submit claims to ND Medicaid while you are waiting for Medicare enrollment to be approved. Once ND Medicaid has confirmed your enrollment with Medicare, we will recoup claims paid to you as primary and you will need to bill Medicare for those claims. Medicaid will become the secondary payer. ND Medicaid will begin recouping claims in May 2024, to give Medicare ample time to approve provider applications.
• If you are enrolled with Medicare: submit claims to Medicare for dates of service of Jan. 1, 2024, and after. Medicaid is now the secondary payer.

Medicaid-enrolled should follow the enrollment instructions found here marriage-and-family-therapists-and-mental-health-counselors-faq-09052023.pdf (cms.gov).

Thank you for your prompt attention to this matter. If you have questions, please reach out to Alyssa Neis at aneis@nd.gov.

Posted 3-14-2024

The Codes Requiring Service Authorization spreadsheet has been updated.  The following drugs have been added and will require service authorization for dates of service on or after April 1, 2024.

Posted 3-6-2024

Ordering/Referring/Prescribing Provider Claim Requirements - Change effective May 1, 2024

Effective for dates of service May 1, 2024, and after, ND Medicaid will require that the ordering/referring/prescribing (ORP) provider’s individual National Provider Identifier (NPI) be present on all 837P transactions (professional claims) for the following services.

• Behavioral Health Rehabilitative Services including:
  • Behavioral Intervention
  • Individual and Group Counseling
  • Intensive in-home for Children
  • Nursing Assessment and Evaluation
  • Skills Integration
  • Skills Restoration
• Diagnostic services including
  • Audiologic Function Tests
  • Diagnostic and Screening Laboratory Services
  • Diagnostic and Screening Radiology and Imaging Services
  • Echocardiograms
  • Electrocardiograms
  • Electronic Analysis or Interrogation of implanted devices
  • Neurodiagnostic Services (EEG, VEP, EMG, Polysomnography)
  • Pulmonary Function Studies / Testing
  • Psychological and Neuro-psychological Testing
• Eyeglasses frames, lenses, and contacts
• Durable Medical Equipment and Supplies
• Hearing Aids
• Occupational Therapy Services
• Physical Therapy Services
• Physician Administered Drugs (any drug administered in the clinic setting)
• Preventive Services including:
  • Immunizations
  • Preventive Evaluation and Management Services
    • Well-Child visits
    • Adult preventive exams
  • Counseling for Risk Factor Reduction
    • Tobacco Cessation
  • Prosthetics
  • Speech Therapy Services

Read the Ordering/Referring/Prescribing Providers policy to learn about which provider types may be ORPs and other requirements. The policy also contains a FAQ section.

Posted 2-29-2024

Attn: Organization Administrators - Deactivating inactive user accounts

It is the responsibility of the Organization Administrator to self-manage their staff members’ user account access to the MMIS Web Portal. The Department strongly encourages all Medicaid providers to establish, at a minimum, one primary and one back-up Organization Administrator.

Effective February 10, 2024, if a user’s account has not been active in 365 days, the MMIS Web Portal system will automatically terminate the user’s account. Questions? Call the Provider Relations Call Center at (701) 328-7098, toll-free (877) 328-7098 or email mmisinfo@nd.gov.

Posted 2-27-2024

Attention Providers: ND Medicaid is aware of a cyber security issue that occurred on February 21, 2024, that impacts providers who use Change Healthcare as their clearinghouse, trading partner, or pharmacy switch vendor. ND Medicaid systems and claims processing are not affected by the cyber security issue. Connections with Change Healthcare will be re-established when Change Healthcare is no longer experiencing cyber security issues.

What does this mean for providers during this temporary shutdown? 

• Change Healthcare will not be able to pick up or access any 835s (electronic remitance advices). Providers can log into the MMIS Web Portal to retrieve. 
• Change Healthcare will not be able to send us any 270 (eligibility) transactions. Providers can log in the MMIS Web Portal or call into the AVRS system to retrieve. 
• Change Healthcare will not be able to send us any 837 (claims) transactions. Providers who have been impacted can submit claims through the MMIS Web Portal or temporarily submit paper claims to:

ND Dept. of Health and Human Services
600 E. Boulevard Ave, Department 325
Bismarck, ND 58505-0250

Providers with questions about this issue should contact their Change Healthcare provider service contact or use Change Healthcare website to find more information.

Posted 2-13-2024

UPDATED ICD-10-CM Coding Guidance - Administering Abrysvo™ (CPT 90678) to Pregnant Individuals 

CDC recommends one dose of Pfizer’s bivalent RSVpreF vaccine (Abrysvo) during RSV season for people who are 32 through 36 weeks pregnant.  For claims to correctly adjudicate for this population of ND Medicaid members,  an ICD-10-CM code specific to the third trimester of pregnancy AND an ICD-10-CM code from the Z3A.32 - Z3A.36 range must be present on the claim and pointed to the specific line that 90678 is billed on. 

Posted 2-5-2024

Changes in Ownership
All changes in ownership (both direct and indirect ownership) are required to be reported within 35 days of the change.  If you are a dually enrolled (Medicare/Medicaid) ownership must be updated in your Medicare and Medicaid record. If you are enrolled with Medicaid, we may be unable to complete the application until the update to the Medicare record has been completed.

The following must be submitted:

1. Statement of whether or not the NPI and/or Tax ID of the business has changed
2. Old owner/s first and last name/s and termination date/s (if applicable)
3. New SFN 1168

• See SFN 1168 instructions before beginning. 

4. Effective date of change
5. Name and contact information of the person sending this request
6. Request must be made by a person listed in the record as an authorized representative, managing employee, board member, or owner.

• Please contact your organization administrator to review the record to ensure the requestor is showing in one of these categories in the web portal prior to submitting your request. If they are not yet in the record, please have your organization administrator add them as an authorized representative and submit an updated SFN 1168 Ownership/Controlling Interest and Conviction form to add them (and any other authorized signers) to the other required sections of the record (Instructions for the SFN 1168).
• If you have not yet registered an organization administrator, please see the “Web Access Registration” FAQ.
• If you have issues with your web portal accounts or passwords, contact customer service at 701-328-7098.

Noridian is currently reviewing the following submission dates as of Monday, February 5 for workloads:

• Individual Application – 1/24/2024
• Group Application – 1/30/2024
• Individual Reactivation – 1/25/2024
• Group Reactivation – current
• Individual Revalidation – 9/29/2023
• Group Revalidation – 6/14/2023
• Affiliation – 1/25/2024
• EFT – 1/29/2024
• Taxonomy Update – 1/31/2024
• Termination Request – 1/26/2024

Any submissions on or before these submission dates can expect either an email/phone call for corrections needed or an approval letter/email within the next 5 business days.

Posted 1-30-2024

Noridian is currently reviewing the following submission dates as of Tuesday, January 30 for workloads:

• Individual Application – 1/19/2024
• Group Application – 1/19/2024
• Individual Reactivation – 1/25/2024
• Group Reactivation – 1/22/2024
• Individual Revalidation – 9/26/2023
• Group Revalidation – 6/14/2023
• Affiliation – 1/19/2024
• EFT – 1/22/2024
• Taxonomy Update – 1/23/2024
• Termination Request – 1/19/2024

Any submissions on or before these submission dates can expect either an email/phone call for corrections needed or an approval letter/email within the next 5 business days.

Posted 1-25-2024

Medicare will begin covering and making payments for the services of marriage and family therapists (MFT), mental health counselors, and addiction counselors on January 1, 2024.  

For dually eligible beneficiaries (those enrolled in both Medicare and Medicaid) who receive Medicaid coverage of services furnished by MFTs or MHCs services furnished by hospital outpatient departments, community mental health centers (CMHC), rural health clinics (RHC), federally qualified health centers (FQHC), or opioid treatment programs (OTP), beginning on January 1, 2024, Medicare will become the primary payer for these services provided by Medicare-enrolled practitioners or providers. 

What does this mean for Medicaid-enrolled licensed marriage and family therapists (LMFT), licensed addiction counselors (all levels), licensed professional counselors (LPC), or licensed professional clinical counselors (LPCC) providers?  If you are currently enrolled in Medicaid as an LMFT, LAC, LPC, or LPCC, you will need to submit your enrollment information to Medicare by January 31, 2024, to prevent any disruption in treatment and payment for dually eligible beneficiaries and payment of claims.    

MFTs and MHCs could begin submitting their Medicare enrollment applications after the CY 2024 PFS final rule was issued on November 2, 2023. The effective date of enrollment may be up to 30 days before the submission of the enrollment application to Medicare, but no earlier than January 1, 2024, which is the date the new benefits authorized by the CAA, 2023 take effect. Newly Medicare-enrolled LMFTs, LPCs, LPCCs and LACs will not be granted an effective date earlier than January 1, 2024, and claims with dates of service before January 1, 2024, will not be payable by Medicare.

Claims submission instructions:

• If you are not yet enrolled with Medicare: submit your Medicare enrollment by Jan. 31, 2024, per the instructions linked below. Continue to submit claims to ND Medicaid while you are waiting for Medicare enrollment to be approved. Once ND Medicaid has confirmed your enrollment with Medicare, we will recoup claims paid to you as primary and you will need to bill Medicare for those claims. Medicaid will become the secondary payer. ND Medicaid will begin recouping claims in May 2024, to give Medicare ample time to approve provider applications. 
• If you are enrolled with Medicare: submit claims to Medicare for dates of service of Jan. 1, 2024, and after. Medicaid is now the secondary payer. 

 Medicaid-enrolled should follow the enrollment instructions found here marriage-and-family-therapists-and-mental-health-counselors-faq-09052023.pdf (cms.gov).

Thank you for your prompt attention to this matter. If you have questions, please reach out to Alyssa Neis at aneis@nd.gov.

Posted 1-18-2024

January 2024 Provider Policy Updates online!

ND Medicaid is committed to having clear, easy-to-find provider guidance and policies. We just published January 2024 Policy updates to the Provider Guidelines, Manuals and Policies webpage.

You'll notice this page has a brand new look. Policies are now located in streamlined lists with topic headings. The General Information for Providers and Behavioral Health Services policy manuals have been broken apart into individually titled policies for your convenience.

The goal is to help you quickly find the policy you need by looking for the policy category and subject matter in our sorted and alphabetized lists.

Provider policies, which now include coding guidelines where appropriate, are organized within these topic headings:

• General Provider Policies  
  • This is where you'll find Provider Information, Enrollment, Appeals, Telehealth, Third Party Liability, Timely Claims Filing, etc.
• Behavioral Health
  • includes Behavioral Health Rehabilitative Services, Substance Use Disorder, etc.
• Dental
• Durable Medical Equipment
• Encounter-Based Services
  • Federally Qualified Healthcare Centers (FQHCs), Rural Health Centers (RHCs), and Indian Health Service (IHS)/Tribally Operated 638 Facilities.
• Institutional Services
  • Hospitals, Ambulatory Surgery Centers, Intermediate Care Facilities, Nursing Facilities, etc.
• Professional Services
  • This is where the majority of policies located in the General Information for Providers Manual are now located, such as Speech Therapy and Health Tracks
• Pharmacy
• Targeted Case Management

Recently updated policies are noted behind the policy title so you know which policies have been updated and when. Changed policy language appears between these symbols «changed policy language».

Upcoming policy changes include a refreshed policy template with definitions and Frequently Asked Questions sections. Questions, comments, concerns? Email Mandy at mrdendy@nd.gov.

Posted 1-16-2024

Noridian is currently reviewing the following submission dates as of Monday, January 15 for workloads:

• Individual Application – 1/3/2024
• Group Application – 1/8/2024
• Individual Reactivation – 1/9/2024
• Group Reactivation – 1/11/2024
• Individual Revalidation – 6/21/2023
• Group Revalidation – 6/14/2023
• Affiliation – 1/4/2024
• EFT – 1/11/2024
• Taxonomy Update – 1/11/2024
• Termination Request – 1/3/2024

Any submissions on or before these submission dates can expect either an email/phone call for corrections needed or an approval letter/email within the next 5 business days. 

Posted 1-12-2024

Medicare will begin covering and making payments for the services of marriage and family therapists (MFT) and mental health counselors (MHC) on January 1, 2024.

For dually eligible beneficiaries (those enrolled in both Medicare and Medicaid) who receive Medicaid coverage of services furnished by MFTs or MHCs services furnished by hospital outpatient departments, community mental health centers (CMHC), rural health clinics (RHC), federally qualified health centers (FQHC), or opioid treatment programs (OTP), beginning on January 1, 2024, Medicare will become the primary payer for these services provided by Medicare-enrolled practitioners or providers. 

What does this mean for Medicaid-enrolled licensed marriage and family therapists (LMFT) and licensed professional counselors (LPC) or licensed professional clinical counselors (LPCC) providers?  If you are currently enrolled in Medicaid as a LMFT, LPC, or LPCC, you will need to enroll in submit your enrollment information to Medicare by January 31, 2024, to prevent any disruption in treatment and payment for dually eligible beneficiaries and payment of claims.   

MFTs and MHCs could begin submitting their Medicare enrollment applications after the CY 2024 PFS final rule was issued on November 2, 2023. The effective date of an MFT’s or MHC’s enrollment may be up to 30 days before the submission of the enrollment application to Medicare, but no earlier than January 1, 2024, which is the date the new benefits authorized by the CAA, 2023 take effect. Newly Medicare-enrolled MFTs and MHCs will not be granted an effective date earlier than January 1, 2024, and claims with dates of service before January 1, 2024, will not be payable by Medicare.

Claims submission instructions:

• If you are not yet enrolled with Medicare: submit your Medicare enrollment by Jan. 31, 2024, per the instructions linked below. Continue to submit claims to ND Medicaid while you are waiting for Medicare enrollment to be approved. Once ND Medicaid has confirmed your enrollment with Medicare, we will recoup claims paid to you as primary and you will need to bill Medicare for those claims. Medicaid will become the secondary payer. ND Medicaid will begin recouping claims in May 2024, to give Medicare ample time to approve provider applications. 
• If you are enrolled with Medicare: submit claims to Medicare for dates of service of Jan. 1, 2024, and after. Medicaid is now the secondary payer.  

Medicaid-enrolled MFTs and MHCs service providers interested in becoming Medicare-enrolled should follow the enrollment instructions found here marriage-and-family-therapists-and-mental-health-counselors-faq-09052023.pdf (cms.gov).

Thank you for your prompt attention to this matter. If you have questions, please reach out to Alyssa Neis at aneis@nd.gov.

Posted 1-10-2024

Noridian is currently reviewing the following submission dates as of Tuesday, January 9 for workloads:

• Individual Application – 12/27/2023
• Group Application – 12/29/2023
• Individual Reactivation – 1/2/2024
• Group Reactivation – 1/5/2024
• Individual Revalidation – 6/20/2023
• Group Revalidation – 6/14/2023
• Affiliation – 12/28/2023
• EFT – 12/29/2023
• Taxonomy Update – 12/20/2023
• Termination Request – 12/28/2023

Any submissions on or before these submission dates can expect either an email/phone call for corrections needed or an approval letter/email within the next 5 business days.

Posted 12-29-2023

Effective for dates of services on or after January 1, 2024, North Dakota Medicaid will begin covering revenue code 0921 for inpatient services. 

Posted 12-28-2023

The 2024 Pharmacy Coverage Policy Manual is posted

• Hepatitis C: Mavyret is no longer a preferred Hepatitis C medication effective January 1, 2024. Generic Epclusa remains a preferred product. Criteria has been updated to allow for one HCV RNA test if the last likely HCV exposure has occurred at least 6 months before the most recent positive test. When requesting this exception, please document the last likely HCV exposure on the PA form or submit documentation for review. There have been several recent updates on Hep C criteria so if your patient has not qualified for Hepatitis C treatment in the past, please reconsider treatment under the new criteria.

• Migraine Prophylaxis: Aimovig is no longer a preferred migraine prophylaxis agent effective January 1, 2024. All members currently on Aimovig will be grandfathered and allowed to continue their medication.

• Discontinuations: Levemir will be discontinued early 2024. Lantus will remain a preferred agent. Toujeo and Tresiba U-200 are preferred agents for doses > 100 units/day and ≤ 200 units/day.

Posted 12-22-2023

Attention Dental Providers: The January 2024 Dental Manual is now available. Individual dental policies have been incorporated into the dental manual. The Health Tracks Orthodontia Screening Policy has been updated. Please contact Sara R. with questions 701-328-4825.

Posted 12-15-2023

The December 2023 ND Medicaid provider newsletter is now available. 

In this edition, learn about:

• An updated Timely Claims Filing policy,
• Benefits of applying fluoride varnish to children in a medical setting, 
• A new lookup tool for drug coverage and more!

If you like to receive this newsletter and other updates sent to your inbox, sign up on the ND Medicaid provider webpage.

We welcome your feedback by email to dhsmed@nd.gov

Thank you for being a ND Medicaid provider and serving Medicaid members.

Posted 12-06-2023

Attention All Providers: North Dakota Medicaid’s Timely Claims Filing Policy has been revised to include clarification on when timely filing may be extended, acceptable forms of documentation for proof of timely filing, Frequently Asked Questions section, etc.

Posted 12-01-2023

Provider Enrollment Update - To better serve North Dakota Medicaid Providers, Noridian provider enrollment specialists will be available to answer questions between the hours of 9 a.m. to 3 p.m. CT, Monday-Friday.

You can reach them at 701-277-6999. You will still have the option to leave a voicemail outside of those core hours.

Provider enrollment specialists can assist with questions about enrollment, revalidations, maintenance items and more. 

Posted 11-20-2023

Attention DME Providers: Effective Nov. 17, 2023, the following Certificate of Medical Necessities (CMN) will no longer be required. SFN 522, SFN 526, SFN 789, SFN 726, SFN 785, SFN 781, SFN 724, SFN 728, SFN 528, and SFN 780.

Posted 11-16-2023

Effective Dec. 1, 2023: Phentermine and Contrave (bupropion/naltrexone) will be covered for weight loss with no prior authorization. Other medications are not covered for weight loss at this time.

Effective Jan. 1, 2024: InPen will be covered. BD and Ulticare will remain as covered insulin syringes. No other insulin syringes will be covered.

Posted 11-13-2023

ND Medicaid is processing prior authorization (PA) requests for Synagis (palivizumab) with the current RSV season onset date of October 28, 2023. Palivizumab determinations will be made based on our current RSV prophylaxis criteria, AAP recommendations and the CDC Health Advisory recommendations addressing the limited supply of Beyfortus (nirsevimab).

• Children aged 8 to 19 months: The CDC recommends palivizumab to be utilized so no further clinical justification is required for that age group.
• Children aged less than 8 months: When nirsevimab supply is exhausted, please utilize the new check box at the bottom of the RSV Prophylaxis PA form to indicate that reason for clinical justification to use palivizumab outside of the CDC recommendations.

To prevent utilization of palivizumab in the case that an infant has acquired immunity through Abrysvo (respiratory syncytial virus vaccine) or nirsevimab, two immunity assessment questions have been added near the bottom of the form. Please also answer these questions appropriately.

Palivizumab PA approvals will allow up to five weight-based doses within six months from the RSV season onset. The PA approval letter will include the number of authorized units and the duration of the approval.

Posted 11-3-2023

ICD-10-CM Coding Guidance - Administering Abrysvo™ (CPT 90678) to Pregnant Individuals 

CDC recommends one dose of Pfizer’s bivalent RSVpreF vaccine (Abrysvo) during RSV season for people who are 32 through 36 weeks pregnant.   In order for claims to correctly adjudicate for this population of ND Medicaid members,  an ICD-10-CM code specific to the third trimester of pregnancy AND an ICD-10-CM code from the Z3A.32 - Z3A.36 range must be present on the claim. 

Posted 11-2-2023

Payment Error Rate Measurement (PERM)

The PERM audit is important to all Medicaid providers because CMS and the review contractor Empower AI will be sending letters to various Medicaid providers requesting medical records to validate that the service was ordered, provided, documented and billed appropriately. Make sure that your release of information/compliance/audit departments are aware and responding to the records requests in a timely manner. Providers should start receiving the letters sometime in late March or April 2024.

The PERM program measures and reports an unbiased estimate of the true improper payments in Medicaid and CHIP (Optional Children’s Group) and produces error rates for each program. The error rates are based on reviews of the fee-for-service (FFS), managed care and eligibility components of Medicaid and CHIP (Optional Children’s Group) in the fiscal year (FY) under review. It is important to note the error rate is not a “fraud rate” but simply a measurement of payments made that did not meet statutory, regulatory, or administrative requirements.

Review Period: The PERM review period is payments made from July through June to align with state fiscal years and to provide additional time to complete the cycle before reporting improper payment rates. The upcoming cycle will review Medicaid and CHIP (Optional Children’s Group) payments made in Reporting Year (RY) 2025 for July 1, 2023 through June 30, 2024

Statistical Contractor (SC) – The Lewin Group (Lewin): The SC will be collecting state’s claims and payment data, processing the data to ensure completeness and compliance with PERM requirements, and selecting samples. The SC may have questions regarding data differences and changes from last cycle, payment methodologies, and identifying Medicaid versus CHIP (Optional Children’s Group) matched payments. The SC is also responsible for national and state improper payment rate calculations that are provided to states at the end of each cycle.

Eligibility Review Contractor (ERC) – Booz Allen Hamilton (Booz Allen): The ERC will be performing eligibility reviews on the samples selected by the SC to inform the resulting improper payment rate. The ERC may have questions regarding topics such as state eligibility policies, eligibility systems, eligibility processes, and eligibility case documentation.

Review Contractor (RC) – Empower AI: The RC will be performing data processing and medical reviews on the samples selected by the SC to inform the resulting improper payment rate. The RC may have questions regarding topics such as state claims adjudication systems; managed care programs; vendors; third-party administrators, like Pharmacy Benefit Managers (PBMs); fee schedules; special programs (e.g., waivers); and claim submission policies.

More information can be found on the PERM webpage. 

Posted 10-27-2023

RSV Vaccine Information: Many new products are available for the 2023-2024 Respiratory Syncytial Virus (RSV) season that have been approved by the Food and Drug Administration (FDA) and recommended by the Center for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP). For details on the 2023-2024 recommendations, please refer to CDC RSV ACIP Vaccine Recommendations.

Summary of ND Medicaid RSV Coverage

• CPT 90678 (Abrysvo™) - Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use
  • Covered for adults 60 and older
  • Covered for pregnant members during 32-36 weeks gestation
• CPT 90679 (Arexvy™)- Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use
  • Covered for adults 60 and older
• CPT 90380 (Beyfortus™)- Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use
• CPT 90381 (Beyfortus™)- Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use 
  • Beyfortus™: Nirsevimab-alip is available through the Vaccines for Children (VFC) Program and should be reported with modifier -SL.
  • Administration of Beyfortus™ should be reported using the following;
    • CPT 96381- Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection. 

Posted 10-25-2023

RSV Update due to Beyfortus™ (nirsevimab) shortage - ND Medicaid is aware that the CDC has issued a Health Alert Network (HAN) Health Advisory for the 2023-2024 respiratory syncytial virus (RSV) season due to the limited supply of Beyfortus™ (nirsevimab).

In response to the CDC’s guidance, ND Medicaid will follow our Synagis® (palivizumab) coverage criteria, season definition, and prior authorization process for infants 8 months to 19 months who have NOT received nirsevimab and whose mothers did not receive Abrysvo™ [Respiratory Syncytial Virus Vaccine].

The RSV season has not yet started in ND.  Once the season starts, ND Medicaid will begin accepting prior authorization requests for palivizumab and determinations will be based on the current AAP guidelines, CDC recommendations, and product availability.

As a reminder, The ND Medicaid RSV season onset is defined as the first of two consecutive weeks when percentage of polymerase chain reaction (PCR) tests positive for RSV is greater than 3%. Season offset is defined as the last of two consecutive weeks when percentage of positive PCR tests for RSV is less than 3%. This data-driven season better aligns Synagis coverage with RSV outbreaks using data from the National Respiratory and Enteric Virus Surveillance System (NREVSS) Midwest Region as reported to the CDC.

Posted 10-23-2023

REMINDER - Therapy claims (special education unit therapy claims excluded) with dates of service July 1, 2022, and after will require the ordering provider to be submitted on each claim submission.

837P Transactions
The referring/ordering provider should be reported at the claim level in Loop 2310A for services such as diagnostic and laboratory services. To report therapy services at the claim detail line level, report the ordering provider in Loop 2420E and/or the referring provider in Loop 2420F.

When there is only one referral use code “DN – Referring Provider." Use“P3 – Primary Care Provider” in the second iteration of the loop to indicate the initial referral from the primary care provider. Use “DK –Ordering Provider” to indicate the ordering provider.

837I Transactions
The referring provider should be reported at the claim level in Loop2310F when the referring provider is different than the attending provider. When the referring provider on a claim detail line is different than what is reported in Loop 2310F, they are reported in Loop 2420D. An ordering provider is not reported on an 837I. Use “DN – Referring Provider” to indicate the referring provider.

Questions? Reach out to the ND Medicaid call center at (877) 328-7098 or mmisinfo@nd.gov.

Attention DME Hearing Aid Device Providers: Effective immediately, when submitting claims for hearing aid batteries V5266, the laterality modifiers, RT and LT, are no longer required.  If the modifiers are submitted on the claim, it will be denied for inappropriate modifier(s). 

DMEPOS providers are still responsible to maintain the member’s file with all the required supporting documents to support the requested number of batteries.  For example: 4 batteries need documentation showing which hearing aid the batteries are used in, the left hearing aid or the right hearing aid.

Posted 10-19-2023

Attention All Providers: Section 13 of the SFN 615 Medicaid Program Provider Agreement has been revised to include the addition of the last paragraph (see below) relating to a provider’s eligibility to bill for services rendered under a supervising provider. Providers are required to use the most recent forms when submitting applications.

Posted 10-16-2023

Claims guidance for when members lose and regain Medicaid eligibility 

Starting April 1, 2023, North Dakota resumed with regular Medicaid renewals for individuals whose coverage was temporarily extended due to the COVID-19 public health emergency to make sure they still qualify.
Some Medicaid members may lose coverage if they do not return information that is needed to process their renewal.

If members lose and then regain eligibility, providers will have 180 days from the date the eligibility was updated to resubmit any claims that were previously denied for no eligibility.

Providers can verify member eligibility by:

1. Logging into ND Health Enterprise MMIS. Click on the Member tab then select Check Eligibility.
2. Using the Automated Voice Response System (AVRS), see AVRS chapter in the General Information for Providers manual, page 7.
3. Calling the Provider Relations Call Center at (701) 328-7098 or (877) 328-7098.

Posted 10-13-2023

On October 12, 2023, ND Medicaid implemented a new prepayment claim editor.  The new claim editor will continue to enforce correct coding and billing practices as well as evaluate current claims against historical claims for editing purposes.

Editing Includes:

• NCCI for Practitioners, Facilities, and DME providers
• Invalid Procedure to Modifier
• Global Surgery
• Procedure to Age
• Add on codes
• Bundled services
• Assistant at Surgery
• Noridian Local Coverage Determinations (LCDs) 
  • L35172 Botulinum Toxin Types A and B
  • L35175 MRI and CT scans of the Head and Neck
  • L34051 Vitamin D Assay Testing
  • L37281 Lumbar MRI
  • L36707 Lab: Controlled Substance Monitoring and Drugs of Abuse Testing
  • L37283 Electrocardiograms
  • L36700 Serum Magnesium
  • L36074 Lab: Flow Cytometry
  • L34038 B-type Natriuretic Peptide (BNP) Testing
  • L38904 Wound and Ulcer Care
  • L34074 Immune Globulin Intravenous (IVIg)
• CMS National Coverage Determinations (NCDs) 
  • 190.12 Urine Culture, Bacterial
  • 190.15 Blood Counts
  • 190.16 Partial Thromboplastin Time (PTT)
  • 190.17 Prothrombin Time (PT)
  • 190.18 Serum Iron Studies
  • 190.21 Glycated Hemoglobin / Glycated Protein
  • 190.22 Thyroid Testing
  • 190.23 Lipid Testing
  • 190.27 Human Chorionic Gonadotropin

Please check this page frequently for updates related to this change.  

Posted 10-2-2023

Attention Providers – October Policy updates are online on the Provider Manuals and Guidelines webpage.

The updated version of the General Information for Providers Manual contains updates to the following policy sections:

• Provider Information (new section on amending medical documentation)
• Medicaid Covered Services
• FQHC
• Hospital Services
• Medical Nutrition Therapy chapter moved to Preventive Services and Chronic Disease Management chapter
• Medications for Opioid Use Disorder (MOUD) formerly Medication Assisted Treatment  
• Noncovered Medicaid Services
• Other Licensed Providers formerly Nurse Practitioner, Certified Nurse Mid-Wives, Clinical Nurse Specialists and Physician Assistants
• Occupational Therapy
• Preventive Services and Chronic Disease Management (New Chapter)
• Physical Therapy
• Physician Services (added in clinical trials information)
• Speech Language Services

 The updated version of the Behavioral Health Services Provider manual contains the following policy section updates:

• Provider Information (new section on amending medical documentation)
• Other Licensed Practitioner (New Chapter)
• Behavioral Health Rehabilitative Services (billing guidelines visual for time-based services)
• Substance Use Disorder Treatment Services (enhanced Covered Services table, additional language, and definitions section)

Updated versions of the Targeted Case Management policies for Serious Mental Illness (SMI)/Serious Emotional Disturbance (SED) and Child Welfare are also posted online. These policies clarify how to calculate time and appropriately bill for time-based service codes.

Posted 09-26-2023

ND Medicaid is adding coverage for routine circumcision for dates of service on and after October 1, 2023. Service Authorization requirements are also being removed for non-routine circumcision.  The following CPT codes are included in this coverage change:

• 54150 - Circumcision, using clamp or other device with regional dorsal penile or ring block
• 54160 - Circumcision, surgical excision other than clamp, device, or dorsal slit, neonate (28 days or less)
• 54161 - Circumcision, surgical excision other than clamp, device, dorsal slit; older than 28 days of age

Posted 09-22-2023

The Codes Requiring Service Authorization spreadsheet has been updated.  The following drugs have been added and will require service authorization for dates of service on or after October 1, 2023.  

• J0174 -  Injection, lecanemab-irmb, 1mg (Leqembi)
• J9226 -  Histerlin implant, 50 mg (Suppreslin LA) 
• Q9157 - Injection, lofersen, 1mg (Qalsody)

Posted 09-20-2023

The following COVID-19 Vaccine Codes for members 19 and over have been added to the Vaccine Fee Schedule 

• 91320 - SARSCV2 VAC 30MCG TRS-SUC IM (COMIRNATY (COVID-19 Vaccine, mRNA) 2023-2024 Formula)
• 91322 - SARSCOV2 VAC 50 MCG/0.5ML IM (SPIKEVAX 2023-2024 Formula)

The following COVID-19 Vaccines are covered under the Vaccines for Children Program (VFC) and should be billed to ND Mediciad at $0.00 or $0.01. 

• 91318 - SARSCOV2 VAC 3MCG TRS-SUC (Pfizer-BioNTech COVID-19 Vaccine 2023-2024 Formula (Yellow Cap))
• 91319-  SARSCV2 VAC 10MCG TRS-SUC IM (Pfizer-BioNTech COVID-19 Vaccine 2023-2024 Formula (Blue Cap))
• 91320 - SARSCV2 VAC 30MCG TRS-SUC IM (COMIRNATY (COVID-19 Vaccine, mRNA) 2023-2024 Formula) members age 12-18
• 91321 - SARSCOV2 VAC 25 MCG/.25ML IM (Moderna COVID-19 Vaccine 2023-2024 Formula)
• 91322 - SARSCOV2 VAC 50 MCG/0.5ML IM (SPIKEVAX 2023-2024 Formula) members age 12-18

The following administration code should be reported with all vaccine codes listed above

• 90480 - ADMN SARSCOV2 VACC 1 DOSE

Posted 8-2-2023

Attention DME Providers: North Dakota Medicaid accepts home sleep studies G0398, G0399, and G0400 for Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). The submitting provider must clarify on the CPAP or BiPAP service authorization request if the home sleep study used is one of the accepted above studies).

Posted 7-25-2023

Health Enterprise (HE) MMIS users are required to clear internet browser cache

Due to the maintenance of HE MMIS (mmis.nd.gov), all users will need to clear their internet browser cache.  Users may experience user interface type of issues if the cache is not cleared out.  Sorry for the inconvenience and thank you for your understanding.  

Please note, these steps may vary, based on your browser version.

Steps for Microsoft Edge
1. Open Microsoft Edge
2. Select Settings, then click on Privacy & services
3. Under Clear Browsing Data, select Choose what to clear
4. At the top choose a time range and select All time
5. Check Cached images and files and Cookies and other site data, then select Clear now 
6. Restart the browser

Steps for Google Chrome
1. Open Google Chrome
2. At the top right, click on More or the settings option
3. Click More tools. Clear browsing data
4. At the top, choose a time range and select All time
5. Next to "Cookies and other site data" and "Cached images and files," check the boxes
6. Click Clear data
7. Restart the browser

Steps for FireFox
1. Open FireFox
2. Select the menu drop-down in the right upper hand corner
3. Select Settings
4. Go to the Privacy & Security tab
5. Click Clear Data under the Cookies and Site Data section
6. Select the Cached Web Content option then click the Clear button 
7. Restart the browser

Posted 7-20-2023

Medicaid Expansion Providers: A Medication Therapy Management Services (MTMS) revision notification is posted on the BCBS ND website.

Posted 7-18-2023

REMINDER: ND Medicaid Health Enterprise MMIS Outage

ND Medicaid is currently undergoing an information technology infrastructure upgrade to our Health Enterprise MMIS (MMIS.ND.GOV) application. This upgrade will require a complete system outage.  All connectivity and access to the system will be shut down during the outage and we will not be able to accept any inbound traffic, including Batch and Realtime Electronic Data Interchange (EDI) X12 transactions (Claims, Eligibility Inquiries, etc.).

If you are an external stakeholder or provider that submits transactions to Health Enterprise MMIS, we are asking that you hold, queue, or disable all transactions to the MMIS system during this outage.  If any transactions are sent during this outage, they will need to be resent after the system maintenance and outage is complete.

Below are the dates and estimated times of the outage.   

* This includes all inbound and outbound traffic and individual user interface access to mmis.nd.gov.

If any changes to these dates and times, updates will be posted on this page.

Thank you for your patience and understanding during this system maintenance outage!  If you have any questions, please reach out to mmisinfo@nd.gov.

Posted 6-30-2023

Fee Schedule Update – The fee schedules for dates of services July 1, 2023, have been posted to the website. Provider rates will receive a 3.0% inflationary increase for the first year of the biennium in accordance with the legislative mandate.

Codes which are priced off a fee schedule have been adjusted with the 3.0% inflation increase accordingly. Codes which are priced using the Relative Value Unit (RVU) methodology have had the conversion factor adjusted. The adjustment of the conversion factor accounts for the implementation of the 2023 RVUs for dates of service on or after July 1, 2023.

Based on the previous calendar 12 month’s claims volume, the new relative value unit adjustments, and a 3.0% inflationary increase for the first year of the biennium, the resulting conversion factor effective for July 1, 2023 dates of service and after is $35.6438. The previous conversion factor was $35.1043. Based on the changes to the relative value units, some fees will increase while others may stay the same or decrease. In the aggregate, the providers whose claims are priced off the RVU methodology will see a 3.0% increase in their reimbursement.

The Ambulatory Surgical Center (ASC) conversion factor effective for July 1, 2023 dates of service and after is $30.24 based on the 3.0% inflation increase.

The Anesthesia conversion factor effective for July 1, 2023 dates of service and after is $25.25 based on the 3.0% inflation increase.

Posted 6-23-2023

Attention All Providers: An update has been made to the SFN 615 Medicaid Program Provider Agreement. Providers are required to use the most recent forms when submitting applications.

Attention DME Providers: Effective May 1, 2023, The Incontinence Products policy has been updated for A4520 -incontinence as follows:

• If member uses 201/month or more, a service authorization is REQUIRED.
• If member uses 200/month or less may submit directly to claims. 
   

Posted 6-19-2023

The June 2023 ND Medicaid provider newsletter is now available. It has a new look, but the same great content.

In this edition, learn about:

• Stay Covered ND resources that providers can use to help educate members about ND Medicaid renewals,
• A scheduled upgrade to ND Medicaid Health Enterprise MMIS in July that will cause a brief system outage and impact provider transactions,
• ND Medicaid coverage of sports physicals, and more!

If you like to receive this newsletter and other updates sent to your inbox, sign up on the ND Medicaid provider webpage.

We welcome your feedback by email to dhsmed@nd.gov. Thank you for being a ND Medicaid provider and serving Medicaid members.

Posted 6-16-2023

UPDATE - As of 10:45 p.m. on June 15, 2023, all operations have returned to normal and the following vulnerability has been resolved: ND Medicaid has been notified by a vendor on 06/15/2023 of a new vulnerability in an application that is associated with electronic claims submission to the MMIS.

Thank you for your patience and understanding.

Posted 6-15-2023

ND Medicaid has been notified by a vendor on 06/15/2023 of a new vulnerability in an application that is associated with electronic claims submission to the MMIS.

Out of an abundance of caution, we are taking immediate action to implement the following mitigation measure:  All Providers, Clearinghouses, and Trading Partners that submit batch 837 files utilizing HTTP or HTTPS protocols will be offline until we can determine the scope of the issue and ensure a suitable remediation is put in place.

We will keep you informed as we gain a better understanding of the situation. Thank you for your patience and understanding.

ND Medicaid Health Enterprise MMIS Outage

ND Medicaid is currently undergoing an information technology infrastructure upgrade to our Health Enterprise MMIS (MMIS.ND.GOV) application. This upgrade will require a complete system outage.  All connectivity and access to the system will be shut down during the outage and we will not be able to accept any inbound traffic, including Batch and Realtime Electronic Data Interchange (EDI) X12 transactions (Claims, Eligibility Inquiries, etc.).

If you are an external stakeholder or provider that submits transactions to Health Enterprise MMIS, we are asking that you hold, queue, or disable all transactions to the MMIS system during this outage.  If any transactions are sent during this outage, they will need to be resent after the system maintenance and outage is complete.

Below are the dates and estimated times of the outage.  
 

* This includes all inbound and outbound traffic and individual user interface access to mmis.nd.gov.

If any changes to these dates and times, updates will be posted on this page.

Thank you for your patience and understanding during this system maintenance outage!  If you have any questions, please reach out to mmisinfo@nd.gov.

Posted 6-7-2023

The web-based Health Tracks/ Well-Child Check Provider Toolkit is now available.

ND Medicaid's Health Tracks provider outreach team will be providing a short training on how to use the Health Tracks toolkit on Wednesday, July 19 from 12:00-12:30 p.m. CDT and Thursday, July 27 from 12:00-12:30 p.m. CDT. If you are not able to attend one of these trainings, this training will be recorded for viewing later.  

Please fill out the registration form and provide your name, email and preferred date. 

Registration closes on July 10, 2023. 

You will receive a Teams meeting invite once you have registered. 

Posted 6-5-2023

The ND Medicaid Institutions for Mental Diseases (IMD) Policy has been updated to clarify the definition of mental diseases.

Posted 6-1-2023

UPDATE – As of 10 p.m. on May 31, 2023, all issues have been resolved and operations have returned to normal.

Posted 5-31-2023

ND Medicaid has been notified by a vendor of a vulnerability in an application that is associated with electronic claims submission to the MMIS. Out of an abundance of caution, we are taking immediate action to implement the following mitigation measure:  All Providers, Clearinghouses, and Trading Partners that submit batch 837 files utilizing HTTP or HTTPS protocols, will be offline until we can determine the scope of the issue and ensure a suitable remediation is put in place.  We will keep you informed as we gain a better understanding of the situation. Thank you for your patience and understanding.

Posted 5-1-2023

The May 2023 General Information for Providers Manual has been posted to the web.  

The Codes Requiring Service Authorization has been updated for May 2023.   The following drugs will require SA effective May 1, 2023; Q5124 - Injection, ranibizumab-nuna, biosimilar, 0.1 mg, Q2042 - Tisagenlicleucel, up to 600 million car-positive viable t-cells, per therapeutic dose. 

Attention Behavioral Health Providers: The Behavioral Health Services Provider Manual has been updated. This manual includes information on 1915(i) services and supports, behavioral health rehabilitative services and substance use disorder services.

Posted 3-22-2023

The Codes Requiring Service Authorization spreadsheet has been updated.   The following drugs will require SA  effective  April 1, 2023:

• C9149   Injection, teplizumab-mrzw, 5mcg 
• J0218    Injection, olipudase alfa-rpcp,1mg
• J1411    Injection, etranacogene dezaparvovec-drlb, per therapeutic dose
• J2182    Injection, mepolizumab, 1mg
• Q5128   Injection, ranibizumab-eqrn, biosimilar, 0.1m

Posted 3-10-2023

The latest edition of the ND Medicaid provider e-newsletter is now available.

In the March 2023 edition, learn about Medicaid Renewals – Stay Covered ND resources that providers can use to help members prepare for the start of Medicaid renewals on April 1, Medicaid coverage for sports physicals, autism-related engagement opportunities, how to apply for membership with the Medicaid Medical Advisory Committee and more!

If you have trouble viewing the e-newsletter, cut and paste the URL into another web browser – Chrome, Firefox or Internet Explorer or Safari for Mac users.

A PDF version is also available.

We welcome your feedback by email to dhsmed@nd.gov. Thank you for being a ND Medicaid provider and serving Medicaid members.

Posted 3-6-2023

MMIS Provider Contact Information

North Dakota Provider Enrollment captures contact information in the North Dakota MMIS web portal. Staff are able to include names for a variety of contact categories within your organization. If you would like to make an update to your provider profile with any names in your facility who would be the most appropriate person for these categories, please have your organization administrator send an email to NDMedicaidEnrollment@noridian.com or fax to 701-433-5956, Attention: ND Medicaid Provider Enrollment.

Posted 2-7-2023

Effective January 28, the Respiratory Syncytial Virus (RSV) season offset criteria has been met. Season offset is defined as the last of two consecutive weeks when percentage of positive PCR tests for RSV is less than 3%, as reported to the Centers of Disease Control and Prevention. The RSV season is identified using data reported by the National Respiratory and Enteric Virus Surveillance System Midwest Region. No further prior authorization requests will be approved. Current Synagis authorization end dates are not impacted.

Posted 1-23-2023

North Dakota Medicaid’s QIO vendor Kepro is happy to announce the launch of a new enhancement for the ANG Provider Portal. This enhancement is the “create case wizard.” With the wizard, providers can create a case, link parties, and attach documents to the case from the homepage.

Join us for an instructor-led training on one of the below dates/times.

Wednesday, Jan. 25, 2023 - 11 a.m. CST - Register for this training  

Thursday, Jan. 26, 2023 - 2 p.m. CST - Register for this training   

Kepro has added the announcement with registration links to its website. The notice has been placed on both the home page and under announcements. Also, the training video is on the site under the training tab.

Posted 1-20-2023 (originally posted 4-18-2022)

Therapy claims (special education unit therapy claims excluded) with dates of service July 1, 2022, and after will require the ordering provider to be submitted on each claim submission.

837P Transactions
The referring/ordering provider should be reported at the claim level in Loop 2310A for services such as diagnostic and laboratory services. To report therapy services at the claim detail line level, report the ordering provider in Loop 2420E and/or the referring provider in Loop 2420F.

When there is only one referral use code “DN – Referring Provider." Use“P3 – Primary Care Provider” in the second iteration of the loop to indicate the initial referral from the primary care provider. Use “DK –Ordering Provider” to indicate the ordering provider.

837I Transactions
The referring provider should be reported at the claim level in Loop2310F when the referring provider is different than the attending provider. When the referring provider on a claim detail line is different than what is reported in Loop 2310F, they are reported in Loop 2420D. An ordering provider is not reported on an 837I. Use “DN – Referring Provider” to indicate the referring provider.

Questions? Reach out to the ND Medicaid call center at (877) 328-7098 or mmisinfo@nd.gov.

Posted 1-19-2023

All Providers: Providers are advised not to edit properties for any state forms. Once a document has been edited by a provider, the platform used to import the forms is not able to determine what boxes where checked, for example, and it is causing delays in processing applications and enrollment updates.

Posted 1-12-2023

Attention DME Providers: Effective January 1, 2023  HCPCS Code A4224 - Supplies for maintenance of insulin infusion catheter will only be allowed when Medicare is the primary payer and has made a payment on the claim.  

For Medicaid primary claims as well as claims where Medicaid is secondary to a commercial health plan the following codes should be utilized based on the product dispensed.

• A4230 - Infusion set for external insulin pump, non-needle cannula type
• A4231 - Infusion set for external insulin pump, needle type
• A4232 - Syringe with needle for external insulin pump, sterile, 3 cc

A 90-day supply will be allowed, with a maximum of one unit per day. From and through dates on the claim should reflect the date dispensed.  No service authorization is required. 

Posted 12-29-2022

Attention Dental Providers: 

The ND Medicaid Dental Manual has been updated.  The following policies have also been updated:

• Prosthodontics
• Palliative Treatment of Dental Pain
• Documentation Requirements for Periodontal Services
• Fluoride Varnish

Please contact Sara R. with any questions or concerns at 701-328-4825.

Posted 12-27-2022

Noridian is currently reviewing the following submission dates as of Tuesday, December 27 for workloads:

• Individual Application – 12/20/2022
• Group Application – 10/25/2022
• Individual Reactivation – 12/14/2022
• Group Reactivation – 11/9/2022
• Individual Revalidation – 12/12/2022
• Group Revalidation – 12/19/2022
• Affiliation – 10/28/2022
• EFT – 12/14/2022
• Taxonomy Update – 12/16/2022
• Termination Request – 12/12/2022

Any submissions on or before these submission dates can expect either an email/phone call for corrections needed or an Approval letter/email within the next 5 business days.

Posted 12-22-2022

The latest edition of the ND Medicaid provider e-newsletter is now available.

In the December 2022 edition, learn about expanded coverage for qualifying new moms, Medicaid 1915(i) State Plan Amendment updates, Stay Covered ND resources and more!

If you have trouble viewing the e-newsletter, cut and paste the URL into another web browser – Chrome, Firefox or Internet Explorer or Safari for Mac users.

A PDF version is also available.

We welcome your feedback by email to dhsmed@nd.gov. Thank you for being a ND Medicaid provider and serving Medicaid members.
  

Posted 12-22-2022

No more paper remittance advices

Effective January 1, 2023 providers will no longer receive paper remittance advices (RAs). Refer to the accessing the remittance advice via provider web portal document to assist you in accessing the RA via the web portal.

If you have never accessed the web portal, you can register by clicking on the "Register" link located in the Provider Registration section of the ND MMIS Health Enterprise Home Page. The user ID and password will be mailed in separate provider letters. Following that step, additional Organization Administrator accounts and other user accounts can be established. Refer to the establishing an organization administrator document. 

Security access will need to be set up with a user’s profile to allow staff to view and download the RA. Once a payment is made, you’ll receive a notice in the “Messages & Announcements” Quick link on the MMIS Home Page. From there you can go to the claims option of the top menu bar and drop down to payment inquiry. Your remittance advice will be located there.

You may contact the call center at 877-328-7098 with any questions.

Posted 12-20-2022

The General Information for Providers Manual has been updated. This manual covers areas regarding provider enrollment and Medicaid Covered services. 

Posted 12-13-2022

The Codes Requiring Service Authorization spreadsheet has been updated.  Please note the following changes in effect for January 1, 2023:   

• Several genetic testing codes have been moved from the General Medical Services tab to the Kepro tab 
• Procedures related to gender affirming care have been added to the KEPRO tab 
• All drugs requiring SA when billed on medical claims are now listed on the Drugs tab including several new requirements

Posted 12-5-2022

Effective January 1, 2023, sports physicals should be coded as CPT^® code 99429-unlisted preventive service and ICD-10-CM code Z02.5.  If a well-child visit and a sports physical occur at the same visit the provider should bill the well-child visit only.

Posted 11-23-2022

ND Medicaid Community Partner Webinar - Join us for our live webinar, Wednesday, Dec. 7 from 12:00-12:45 p.m. CT to learn how partners, providers and other community stakeholders can help prepare ND Medicaid members for the end of the Public Health Emergency. Registration is required.

Posted 11-17-2022

No more paper remittance advices

Effective January 1, 2023 providers will no longer receive paper remittance advices (RAs). Refer to the accessing the remittance advice via provider web portal document to assist you in accessing the RA via the web portal.

If you have never accessed the web portal, you can register by clicking on the "Register" link located in the Provider Registration section of the ND MMIS Health Enterprise Home Page. The user ID and password will be mailed in separate provider letters. Following that step, additional Organization Administrator accounts and other user accounts can be established. Refer to the establishing an organization administrator document. 

Security access will need to be set up with a user’s profile to allow staff to view and download the RA.  Once a payment is made, you’ll receive a notice in the “Messages & Announcements” Quick link on the MMIS Home Page. From there you can go to the claims option of the top menu bar and drop down to payment inquiry. Your remittance advice will be located there.

You may contact the call center at 877-328-7098 with any questions.

Posted 11-9-2022

International Fraud Awareness Week 11/13-11/19/2022

The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year.

In honor of International Fraud Awareness Week 11/13-11/19/2022, below are resources to help providers prevent, detect, and report fraud against the Medicaid program.

• Avoiding Medicare and Medicaid Fraud and Abuse booklet and instructional materials to present the information to your employees: https://oig.hhs.gov/compliance/physician-education/
• Health care compliance resources and toolkits offered by the U.S. Department of Health and Human Services: https://oig.hhs.gov/compliance/
• Annual Report of the Departments of Health and Human Services and Justice, Health Care Fraud and Abuse Control Program FY 2021: FY 2021 HCFAC Report (hhs.gov)
• Quick Facts on Health Care Fraud Offenses from the U.S. Sentencing Commission FY 2021:   Quick Facts on Health Care Fraud Offenses (ussc.gov)

Report suspicions of North Dakota Medicaid fraud, waste, and abuse via:

• Phone: (701) 328-4024 or 1-800-755-2604 (option 3)
• Email: MedicaidFraud@nd.gov
• Complete a SFN 20 and return it via mail, fax, or e-mail as instructed on the form
• Website information:  Medical Services Fraud and Abuse | Health and Human Services North Dakota

Posted 9-28-2022

The latest edition of the ND Medicaid provider e-newsletter is now available. In the September 2022 edition, learn about expanded postpartum coverage for qualifying new moms, newly redesigned ND Medicaid ID cards, funding opportunities to expand in-home and community-based care services for people with disabilities and more.

If you have trouble viewing the e-newsletter, cut and paste the URL into another web browser – Chrome, Firefox or Internet Explorer or Safari for Mac users.

 A PDF version is also available. We welcome your feedback by email to dhsmed@nd.gov. Thank you for being a ND Medicaid provider and serving Medicaid members.

Posted 9-21-2022

Effective Oct.1, ND Medicaid will cover Omnipod DASH and Omnipod 5 Tubeless Automated Insulin Delivery Systems. 

These will be covered through pharmacy point-of-sale billing for Medicaid members with Type 1 diabetes who are under the age of 21. Providers can refer to the Preferred Drug List for prior authorization forms, clinical criteria and frequently asked questions regarding coverage and billing. 
 

Effective Sept. 7, to better align Synagis coverage with respiratory syncytial virus (RSV) outbreaks as reported to the Centers of Disease Control and Prevention, the RSV season will be identified using data reported by the National Respiratory and Enteric Virus Surveillance System (NREVSS) Midwest Region.  

The RSV season onset will be defined as the first of two consecutive weeks when percentage of polymerase chain reaction (PCR) tests positive for RSV is greater than 3%. 

Season offset will be defined as the last of two consecutive weeks when percentage of positive PCR tests for RSV is less than 3%. 

What to do next - prior authorization requests
Up to five weight-based doses will be authorized within six months from the RSV season onset. No further prior authorization requests (PA) will be approved following the season offset. The PA approval letter will include the number of authorized units and the duration of the approval. 

The current season started on Aug. 27, 2022.

Posted 9-21-2022

HHS has established a set rate of reimbursement for HCPCS E2599, a speech generating device eye gazing camera of $3642.78. This rate is effective for service authorization request start dates of Sept. 1, 2022, and forward.

Posted 8-24-2022

Effective January 1, 2023, North Dakota Medicaid will require a valid HCPCS code for revenue code 250 on all outpatient services. A NDC must also be submitted if the HCPCS code requires it.

Posted 8-2-2022

Attention DME Hearing Aid Device Providers: Effective July 1, 2022, ND Medicaid will cover BICROC ITE and BTE per the hearing aid device policy’s coverage criteria. When submitting a service authorization, providers are to use the binaural codes V5211 or V5221 and the binaural dispensing code V5240 when providing 1 hearing aid and 1 contralateral routing device with a unit of 1. The BICROC and dispensing code reimbursement will match other binaural hearing aid and dispensing existing rates.

Posted 7-13-2022

Attention Dental Providers: The ND Medicaid Dental Manual has been updated.

Posted 6-28-2022

The General Information for Providers Manual has been updated.  This manual covers areas regarding provider enrollment and Medicaid Covered services.

Posted 6-27-2022

Fee Schedule Update – The fee schedules for dates of services July 1, 2022, have been posted to the website. Provider rates will receive a one-fourth inflationary increase for the second year of the biennium in accordance with the legislative mandate.

Codes that are priced off a fee schedule have been adjusted with the one-fourth percent inflation increase accordingly. Codes that are priced using the Relative Value Unit (RVU) methodology have had the conversion factor adjusted. The adjustment of the conversion factor takes into account the implementation of the 2022 RVUs for dates of service on or after July 1, 2022.

Based on the previous calendar 12 months’ claims volume, the new relative value unit adjustments, and a one-fourth percent inflationary increase for the second year of the biennium, the resulting conversion factor effective for July 1, 2022 dates of service and after is $35.1043. The previous conversion factor was $34.9990. Based on the changes to the relative value units, some fees will increase while others may stay the same or decrease. In the aggregate, the providers whose claims are priced off the RVU methodology will see a one-fourth percent increase in their reimbursement.

The Ambulatory Surgical Center (ASC) conversion factor effective for July 1, 2022 dates of service and after is $29.36 based on the one-fourth percent inflation increase.

The Anesthesia conversion factor effective for July 1, 2022 dates of service and after is $24.51 based on the one-fourth percent inflation increase.

The latest edition of the N.D Medicaid Provider e-newsletter is now available.

In the June 2022 edition, learn about efforts to increase access to preventive health care services for children, benefits of primary care providers applying fluoride varnish during well-child visits, upcoming training opportunity for Medicaid 1915(i) providers, a new timely filing policy for Medicaid claims and more!

If you have trouble viewing the e-newsletter, cut and paste the URL into another web browser – Chrome, Firefox or Internet Explorer or Safari for Mac users.

A PDF version is also available.

We welcome your feedback by email to dhsmed@nd.gov.  

Thank you for being a N.D. Medicaid provider and serving our Medicaid members.

Announcing new Medicaid 1915(i) training and technical assistance opportunity for providers

Starting in August, the North Dakota Department of Human Services, in partnership with the Corporation for Supportive Housing (CSH), will be offering a six-week Medicaid Academy that focuses on providing services through the state’s Medicaid 1915(i) State Plan Amendment.

This training opportunity will help new Medicaid 1915(i) providers:

• Complete their group and individual provider enrollments,
• Develop policy and procedures,
• Update their business model to incorporate Medicaid billing, claims submissions and more.  

The Medicaid Academy is also available for providers who have started the enrollment process and for those who are currently enrolled but need technical assistance.

In addition to the six weekly training sessions, providers will have the opportunity to join a weekly technical assistance call and connect by email with a member of the CSH team for any additional technical assistance needs.

To register or to learn more about the Medicaid Academy, contact Monica Haugen, Behavioral Health Division Medicaid 1915(i) program administrator at mohaugen@nd.gov.

Posted 6-21-2022

Noridian is now able to accept secure emails from providers and providers are encouraged to submit information via secure email versus faxing.

EFT Requirement: The Department of Human Services is requiring all enrolled providers to participate in electronic funds transfers (EFT) in order to receive Medicaid payments.  (NDCC 50-24.1-42).

Currently, enrolled providers have until December 31, 2022 to comply. Because this requirement is specific to Medicaid payments, it is advised that you also enroll with EFT for Medicaid Expansion, Blue Cross and Blue Shield of North Dakota (BCBSND) if you’re participating in that Managed Care Organization. EFT enrollment for BCBSND’s Medicaid Expansion network can be submitted through Availity at https://apps.availity.com/availity/web/public.elegant.login within the Transaction Enrollment section. BCBSND may be reached by emailing prov.net@bcbsnd.com or calling (800) 756-2749.

Complete and return the following items to ND Medicaid Enrollment by faxing 701-433-5956. If you prefer to send via secure email, you may either submit securely or request a secure link from Noridian staff NDMedicaidEnrollment@Noridian.com. You’ll need to submit a SFN 661 and a bank letter or voided check. The information on the form must match the information provided in the bank letter or voided check.

Posted 5-26-2022

Attention Dental Providers: ND Medicaid will hold a virtual training session on Wednesday, June 1, 10-11 a.m. CT, on filing secondary dental claims using the MMIS web portal and e-attachments. Join virtually by computer or mobile device (video and audio) Click here to join the meeting or by phone (701) 328-0950, Conference ID: 739 138 311#.

Posted 5-16-2022

The Medication Therapy Management Provider (MTM) Manual has been updated and renamed Provider Manual for Pharmacy Medical Billing. It now includes additional medical services that may be billed by pharmacies/pharmacists.

Posted 5-13-2022

The General Information for Provider Manual has been updated. This manual covers areas regarding provider enrollment and Medicaid covered services.

Posted 5-12-2022

Reminder that the North Dakota Department of Human Services Timely Filing Policy has changed for claim dates of service on or after Jan. 1, 2022.

Posted 4-18-2022

Therapy claims (special education unit therapy claims excluded) with dates of service July 1, 2022, and after will require the ordering provider to be submitted on each claim submission.

837P Transactions
The referring/ordering provider should be reported at the claim level in Loop 2310A for services such as diagnostic and laboratory services. To report therapy services at the claim detail line level, report the ordering provider in Loop 2420E and/or the referring provider in Loop 2420F.

When there is only one referral use code “DN – Referring Provider." Use“P3 – Primary Care Provider” in the second iteration of the loop to indicate the initial referral from the primary care provider. Use “DK –Ordering Provider” to indicate the ordering provider.

837I Transactions
The referring provider should be reported at the claim level in Loop2310F when the referring provider is different than the attending provider. When the referring provider on a claim detail line is different than what is reported in Loop 2310F, they are reported in Loop 2420D. An ordering provider is not reported on an 837I. Use “DN – Referring Provider” to indicate the referring provider.

Questions? Reach out to the ND Medicaid call center at (877) 328-7098 or mmisinfo@nd.gov.

Posted 3-28-2022

The North Dakota Medicaid Program Integrity Unit provided program updates on Feb. 23 and 24, 2022 by video conference.  Providers can access the PowerPoint and Q & A of that presentation. 

If you were not sent an email invitation to the event and would like to be included in future video conferences, please email Missy Rosales at melrosales@nd.gov.

The latest edition of the N.D Medicaid Provider e-newsletter is now available.

In the March 2022 edition, learn about member eligibility renewals, primary care provider referrals, a new timely filing policy for Medicaid claims, common reasons why claims are denied or suspended and more!

If you have trouble viewing the e-newsletter, cut and paste the URL into another web browser – Chrome, Firefox or Internet Explorer or Safari for Mac users.

A PDF verison is also available.

We welcome your feedback by email to dhsmed@nd.gov.  

Thank you for being a N.D. Medicaid provider and serving our Medicaid members.

Posted 3-18-2022

Attention Dental Providers: As of May 1, 2022, North Dakota Medicaid will no longer be accepting any paper dental claims.  Paper dental claims received on or after May 1, 2022, will be returned to the provider unless an exemption has been approved by North Dakota Medicaid. 

Requesting an Exemption
Providers who are not included on the automatic exemption list above and wish to receive an exemption will need to submit an exemption request in writing or via email using the department-approved form.

Submit by fax, email, or mail to:

Fax: (701) 328-1544 - ATTN:  Michelle Adams
Email: mladams@nd.gov
Mailing Address:

Medical Services – ATTN: Michelle Adams
ND Department of Human Services
600 E. Boulevard Ave., Dept 325
Bismarck, N.D. 58505-0250

All dental claims must be submitted as/an 837D electronic transaction or through the ND Provider Web Portal.

Electronic claims submission instructions can be located on our webpage.

NOTE: FAXED claims are not accepted for submitting for payment.

If you have questions or concerns, contact ND Medicaid Call Center at (877) 328-7098 / (701) 328-7098 or email mmisinfo@nd.gov.

Posted 1-26-2022

Attention Dental Providers: The ND Medicaid Dental Manual has been updated and is now available. This manual includes all CDT 2022 code updates.

Posted 1-6-2022

Attention Behavioral Health Providers: A new provider manual specific to behavioral health services covered by ND Medicaid is now available. The manual contains chapters on:

• Partial Hospitalization Psychiatric (PHP) Services
• 1915(i) Behavioral Health Services
• Psychiatric Residential Treatment Facilities (PRTFs)
• Qualified Residential Treatment Programs (QRTPs)
• Rehabilitative Services
• Substance Use Disorder Treatment Services

Posted 1-3-2022

Attention DME Providers: Fee Schedules and the Professional Fee Schedule, both effective Jan. 1, 2022, have been posted to the ND Medicaid provider fee schedule webpage.