“In every act of care, we sow the seeds of hope and nurture the blossoms of recovery.” - Unknown.
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We have made several enhancements to better serve ND Medicaid providers by optimizing the provider enrollment process.
Our continued efforts include:
- Providing live support for enrollment-related inquiries:
- Email Noridian: NDMedicaidenrollment@noridian.com
- Hours: Monday- Friday, 8 a.m. to 5 p.m. CT
- Allowing providers 30 days to respond to requests for information instead of 14 days:
- Noridian staff will attempt to contact the provider by phone if there is no response approaching the 30-day deadline.
- Keeping providers informed and on track with upcoming and past-due revalidation lists:
- Posting both lists six months in advance.
- Offering access to these lists on our Provider Enrollment webpage.
- Emailing notices 90 days in advance instead of the previous 30 days.
- Sending reminders at 60 days and 30 days.
- Making reminder calls to address any questions you may have.
- Revalidating durable medical equipment enrollments every three years, aligning with Medicare.
- Updated application requirements for multiple provider types, streamlining the enrollment process.
- Encouraging providers to go to the Provider Enrollment webpage to access the most current information and forms.
Update your phone number, email address, and other contact information to ensure successful and timely delivery of notices and announcements.
Claims Corner 
Top Claims Denials:
- Timely filing denials. Claims are being submitted past the timely filing limit. Refer to the department’s Timely Claims Filing policy found on the Provider Guidelines, Manuals, and Policies webpage.
General Reminders:
- Late or additional charges: When adding late charges or additional charges to an already processed claim, adjust the original and add any additional charges to the adjusted claim. Do not send in another original claim.
- Attachments: Attachments to claims may be required for validation of medical necessity, proof of insurance, referrals, service authorizations, and more. There are two forms that can be used for submission of claims attachments, the SFN 177 or the MMIS Web Portal confirmation page. One of these documents needs to accompany the claims attachments. Review our Claims Attachments policy for further information.
ND Medicaid Quality Measure Tips 
We want your patients and our members to be as healthy as possible by making sure they get the preventive care and chronic condition management they need.
The National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS®) and the Centers for Medicare and Medicaid Services’ measures are important tools as you guide your patients to quality care.
CPT Category II codes are supplemental tracking codes used for quality performance measurement and data collection. Take advantage of the ND Medicaid Quality Measure Tip Sheet to help your practice understand coding recommendations.
Administratively, capture all required HEDIS data through your claims by adding codes for certain preventive care services and test results. This helps us get a more complete picture of our members’ health and helps you to identify and address open care opportunities.
Diabetic Supply Coverage Updates 
Diabetic supply coverage changes, effective Jan. 1, 2025, will be reflected in the 2025 Preferred Drug List.
This list will be posted the second week of December 2024 on the Acentra Health website.
Some changes you can expect are:
Test strips:
- Accu-Chek Guide test strips will be the only test strips covered.
- Contour and OneTouch test strips will no longer be covered.
Insulin Syringes:
- BD/embecta insulin syringes will be the only insulin syringes covered.
- Ulticare insulin syringes will no longer be covered.
Pen Needles:
- BD/embecta (Ultra-Fine) and Owen Mumford (Unifine) pen needles will continue to be covered.
- All other brands will not be covered.
Continuous Glucose Monitors (CGM):
- Dexcom will remain the sole preferred CGM.
- Nonpreferred 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.
- 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.
Biosimilar Coverage Updates 
Biosimilar coverage changes, effective Jan. 1, 2025, will be reflected in the 2025 Preferred Drug List.
This list will be posted the second week of December 2024 on the Acentra Health website.
Some changes you can expect are:
Adalimumab:
- Humira will remain preferred without prior authorization (PA).
- Multiple biosimilars are also preferred without PA (i.e., Cyltezo, Simlandi, Yusimry, adalimumab-adaz, and adalimumab-adbm).
- All other adalimumab biosimilars will require PA.
Bevacizumab:
Bevacizumab billing is allowed on the medical benefit only.
- Mvasi and Zirabev will be preferred without PA.
- Avastin and its other biosimilars will require PA.
- This does not include bevacizumab billed with C9257 for ophthalmology use.
Filgrastim:
- Medical Benefit:
- Granix, Nivestym, and Zarxio will be the preferred agents without PA.
- Neupogen and its other biosimilars will require PA.
- Pharmacy Benefit:
- Neupogen and Releuko will be the preferred agents without PA.
Pegfilgrastim:
- Medical Benefit:
- Neulasta, Neulasta Onbody, Nyvepria, and Udenyca Onbody will be the preferred agents without PA.
- All other biosimilars will require PA.
- Pharmacy Benefit:
- Fulphila, Fylnetra, Neulasta Onpro, and Udenyca Onbody will be preferred agents without PA.
Infliximab:
Infliximab billing is allowed on the medical benefit only.
- Avsola and Inflectra will be the preferred agents without PA.
- Remicade and its other biosimilars will require PA.
Rituximab:
Rituximab billing is allowed on the medical benefit only.
- Riabni, Ruxience, and Truxima will be the preferred agents without PA.
- Rituxan will require PA.
Tocilizumab:
- Medical and Pharmacy Benefit:
- Tyenne will be the preferred agent without PA.
- Actemra and its other biosimilars will require PA.
Trastuzumab:
Trastuzumab billing is allowed on the medical benefit only.
- Kanjinti and Trazimera will be the preferred agents without PA.
- Herceptin and its other biosimilars will require PA.
Drug Prior Authorization Updates 
Effective Immediately
These drug prior authorizations (PA) changes are on the current Preferred Drug List, located in the Pharmacy Coverage Policy Manual.
- No longer requires PA:
- Repatha
- Cugaquig (J1551)
- Gammaplex (J1557)
- Xembify (J1558)
- Now requires PA:
- Hyqvia (J1575)
- Tremfya (J1628)
- Invokana
- Invokamet
- Pimecrolimus cream
Effective Jan. 1, 2025
These changes will be reflected in the 2025 Preferred Drug List. This list will be posted the second week of December 2024 on the Acentra Health website.
- PCSK9 inhibitors:
- Praluent will no longer be preferred and will require a step through Repatha.
- Please transition members to Repatha now.
- Growth Hormone:
- Norditropin and Genotropin will be preferred with clinical PA.
- Please transition members to either Norditropin now or Genotropin after Jan. 1, 2025.
- Nutropin AQ is being discontinued and will no longer be preferred.
- Cystic Fibrosis Tobramycin:
- Bethkis will no longer be preferred.
- Please transition members to generic Tobi now, which does not require PA.
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Effective Immediately
Changes to brand name requirements are reflected on the current Preferred Drug List, located in the Pharmacy Coverage Policy Manual.
No longer brand-name required:
If a member requires brand name (brand is medically necessary), a Dispense as Written 1 (DAW) prior authorization must be submitted. DAW criteria must be met. This includes a trial of all available generics along with submission of a Food and Drug Administration (FDA) MedWatch form for each generic trial. This process helps us meet the requirement to inform the FDA when a marketed product is not producing expected results.
If the below products have authorized generics, prescriber-requested DAW will not be approved:
- Adderall XR
- Concerta
- Mydayis
- Viibryd
Brand-name required:
Prescribers should not submit a DAW request based on ND Medicaid brand preference. When the payer requires brand name, pharmacies can automatically substitute and bill without prescriber intervention. Drugs with new brand-name requirements are:
- Ritalin LA
Effective Jan. 1, 2025
These changes will be reflected in the 2025 Preferred Drug List. This list will be posted the second week of December 2024 on the Acentra Health website.
- Brand name Focalin XR is preferred instead of the generic.
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ND Medicaid will not pay for Synagis for the following members:
- Infants eligible to receive Beyfortus through the Vaccine for Children (VFC) program.
- Infants who have received immunity through a maternal Respiratory Syncytial Virus (RSV) vaccine and/or Beyfortus for RSV prophylaxis during the current season.
RSV season is based on the percentage of Polymerase Chain Reaction (PCR) testing and is defined by the following:
- Season Onset: Begins with the first of two consecutive weeks where the percentage of RSV-positive PCR tests exceeds three percent.
- Season Offset: Ends with the last of two consecutive weeks where the percentage of RSV-positive PCR tests drops below three percent.
These percentages are tracked using data from The National Respiratory and Enteric Virus Surveillance System for region 8. This system allows public health authorities to monitor RSV trends and plan interventions accordingly.
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Qualifying Medicaid members can live successfully in their communities with 1915(i) Behavioral Health Supports and Services. Members work with their care coordinator to create a person-centered care plan. Services and supports in their plan may include housing support, peer support, family peer support for youth, respite, employment support, and more.
Pre-screen your patients by asking the following questions. They may qualify if they answer is yes to all.
- Are they currently enrolled in Medicaid or Medicaid Expansion? (If no, are they potentially eligible?)
- Is the patient’s household income at or below 150% of the Federal Poverty Level?
- Does the patient have a World Health Organization Disability Assessment Schedule (WHODAS) score of 25+? Alternatively, do they have a Daily Living Assessment-20 (DLA-20) score of 5 or below from a human service center-administered assessment?
- Does the patient live in a home and community-based setting? (Not living in a nursing home, intermediate care facility, inpatient treatment facility, etc.)
- Does the patient have a qualifying behavioral health diagnosis?
Help patients gather application requirements. Your office staff can administer the WHODAS if an applicant doesn’t have a current score. Applicants can also contact the Customer Support Center at 1-866-614-6005, 711 (TTY) to schedule a WHODAS. See WHODAS training requirements on page 2 of our Needs-Based Eligibility policy.
Document their behavioral health diagnosis. Print out documentation of the applicant’s qualifying diagnosis and include your name or fill out page 3 of the 1915(i) application.
Learn more on our 1915(i) webpage.