Welcome to the December 2023 North Dakota Medicaid provider newsletter.
“It's not so much how busy you are, but why you are busy.” - author Mary Flannery O'Connor.
Thank you for every busy day spent serving North Dakota Medicaid members across the state!
Provider enrollment specialists are one call away
To better serve ND Medicaid providers, Noridian provider enrollment specialists will be available to answer questions between the hours of 9 a.m. - 3 p.m. CT Monday through 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.
Policy update! Timely claims filing
ND Medicaid’s Timely Claims Filing policy was updated in November 2023. This policy tells you when original Medicaid primary claims must be received and under what circumstances the 180-day deadline may be extended. You will also find acceptable forms of documentation accepted as proof of timely claim filing.
The policy also explains timely filing circumstances when there is a retroactive member or provider eligibility, claims with third-party liability, Medicare crossover claims and claims submitted for reconsideration.
New to ND Medicaid is a Timely Filing Override Request Form. The form must include a reason for the timely filing override request and supporting documentation. This process does not replace the current appeals, reconsideration or resubmission process.
New to this policy is a Frequently Asked Questions section. The full policy is available on the Provider Guidelines, Manuals and Policies webpage under Administrative policies. If you have further questions, reach out to the Medical Services Call Center at (701) 328-7098, (877) 328-7098 or email mmisinfo@nd.gov.
January 2024 provider policy updates will be posted online mid-January
Policies in the General Information for Providers Manual and the Behavioral Health Services Provider Manual will be posted online in mid-January 2024 on the Provider Guidelines, Manuals and Policies webpage.
2024 Noridian Claims Operations Call Center holiday and training closures
The Noridian Claims Operation Call Center will be closed from 12:15 p.m. to 2:45 p.m. CT for training on these dates.
| Jan. 12 | Jan. 19 | Jan. 26 |
| Feb. 9 | Feb. 16 | Feb. 23 |
| March 8 | March 15 | March 22 |
| April 5 | April 12 | April 19 |
| May 3 | May 10 | May 17 |
| June 7 | June 14 | June 21 |
| July 12 | July 19 | July 26 |
| Aug. 9 | Aug. 16 | Aug. 23 |
| Sept. 13 | Sept. 20 | Sept. 27 |
| Oct. 11 | Oct. 18 | Oct. 25 |
| Nov. 8 | Nov. 15 | Nov. 22 |
| Dec. 6 | Dec. 13 | Dec. 20 |
The call center will also be closed on these holidays.
| New Year's Day | Monday, Jan. 1 |
| Good Friday | Friday, March 29 |
| Memorial Day | Monday, May 27 |
| Independence Day | Thursday, July 4 |
| Labor Day | Monday, Sept. 2 |
| Thanksgiving | Thursday, Nov. 28 and Friday, Nov. 29 |
| Christmas Day | Wednesday, Dec. 25 |
Applying fluoride varnish in a medical setting is a great way to prevent cavities
During this time of the year, many parents bring their child to the clinic for an illness or well-child visit.
ND Medicaid Health Tracks is encouraging providers who offer fluoride varnish to provide it during these visits. Dental cavities are the most common chronic preventable childhood disease in the United States. Fluoride varnish is a topical fluoride that helps prevent the need for dental fillings.
ND Medicaid pays for fluoride varnish in a medical setting for members ages six months through 20 years old using the CPT® code 99188 twice per calendar year. **For RHC, FQHC, and IHS clinics, fluoride varnish applications falls under the medical encounter code.
If your office is interested in applying fluoride varnish, but has not yet completed the free and minimal training, you can reach out to the Health Tracks Provider Outreach Team at htprovideroutreach@nd.gov to learn more on how to get started.
View the Smiles for Life training.
Coder's Corner - New place of service code for treating unsheltered people and interactive complexity code
Interactive Complexity CPT® 90785
Interactive complexity (90785) is an add-on code specific for psychiatric services and refers to communication difficulties during the psychiatric procedure. Add-on codes may only be reported in conjunction with other codes, never alone. Interactive complexity (90785) may be billed in addition to the following CPT® codes: 90791, 90792, 90832, 90833, 90834, 90837, 90838 and 90853. Billing 90785 with any other CPT® code will result in denial of the claim line.
New place of service code for treating unsheltered people
Effective Oct. 1, 2023, Centers for Medicare and Medicaid Services (CMS) created a new place of service (POS) code to report services to unsheltered people.
POS 27 – Outreach Site/Street - A nonpermanent location on the street or found environment, not described by any other POS code, where health professionals provide preventive, screening, diagnostic and/or treatment services to unsheltered homeless individuals.
Prior to Oct. 1, these services would have been reported under POS 99 – Other Place of Service. If you are currently providing services or treatment to unsheltered individuals, make sure to report the new POS code. Full list of CMS Place of Service Code Set.
New J-Codes requiring service authorization
The following physician-administered drugs (J-Codes) will require service authorization effective Jan. 1, 2024.
| J0202 | Lemtrada |
| J0217 | Lamzede |
| J1304 | Qalsody |
| J1412 | Roctavian |
| J1413 | Elevidys |
| J2508 | Elfabrio |
| J3401 | Vyjuvek |
| J9321 | Epkinly |
| J9333 | Rystiggo |
| J9334 | Vyvgart Hytrulo |
A complete list of drugs requiring service authorization can be found on the Provider Guidelines, Manuals and Policies webpage under the heading Additional Information and Resources.
Hepatitis C updates
There is a new prior authorization (PA) form and updated coverage criteria in the most recent preferred drug list on the prior authorization webpage.
Changes to note are:
Chart notes, imaging/fibrosis score, drug screens or HCV RNA labs are not required
- For HCV RNA labs, simply document the date(s) of the detectable result.
- For any patient with fibrosis, even F1, you only need one HCV RNA lab within the past two years.
- For any patient without known fibrosis, two HCV RNA labs are required. The HCV RNA labs need to only be three months apart with the most recent within the last two years.
Adherence requirements have been removed for initial treatment
For re-treatment after incomplete therapy, adherence-focused education is required. MTM can be used anytime a member may benefit from adherence counseling, including to meet this requirement.
- Sobriety requirements have been removed. See more information about the harm reduction pathway for active users below.
- Member and provider attestation forms are no longer required. Continue to counsel members on readiness, pregnancy and Hepatitis C transmission prevention.
Quantity Limits
The entire course of sofosbuvir/velpatasvir (generic Epclusa), Mavyret, and Vosevi must be dispensed at the initial fill.
- Overrides have been entered for members who have already partially completed their treatment so they can finish their course.
Harm Reduction Pathway
This pathway was created to allow members who have substance use disorders and are actively injecting drugs or using alcohol to receive treatment for Hepatitis C.
A webinar has been created to assist health professionals with engaging in harm reduction conversations.
Scroll to the bottom of the Viral Hepatitis Elimination webpage to see the following helpful resources:
1. Medicaid Hepatitis C Treatment Criteria webinar
2. Harm Reduction Primer for Health Professionals Treating Hepatitis C webinar
3. ND Hepatitis C Elimination Plan
Additional harm reduction resources are available on the Syringe Service Programs webpage.
Public Health follow-up of reportable diseases
North Dakota Health and Human Services (HHS) is grateful to you, the dedicated providers who work tirelessly to ensure the safety and well-being of North Dakotans. We truly appreciate your partnership and are requesting your assistance.
When talking to your patients diagnosed with reportable conditions, please tell them that a representative from the HHS Public Health Division will be contacting them.
We recognize the potential hesitancy some patients may feel about engaging with HHS. That is why your support is so important. Patients appreciate knowing that HHS will be making a follow-up call to ask about things of public health importance. These follow-ups ensure that the treatment and care they are receiving from you can be extended to others who may also need it. This bridge of communication between HHS and patients is important and serves as the cornerstone for disease prevention, surveillance and education.
Through collaborative efforts, we can help North Dakota become the healthiest state in the nation. Thank you for your support.
Quick billing tip: Dental
Dental services performed in a hospital under general anesthesia should be billed to ND Medicaid under code G0330. The facility payment rate is much higher and far more appropriate than what was used in the past. G0330 has been effective since Jan. 1, 2023.
G0330 - Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room.
New lookup tool for drug coverage
This tool can be accessed in two ways:
1. NDC Drug Lookup tab on the left side of ND Medicaid prior authorization website.
2. Directories drop down on the top of the ND MMIS web portal.
Instruction on how to use
1. Search using the NDC or Drug Name (partial drug names are allowed)
2. Enter the claim date of service (default is current date)
3. Select the Benefit Plan 100-ND Medicaid Fee for Service (other benefit plan selections may be used when appropriate)
This tool will display the following on a selected NDC:
- age limits
- quantity limits
- prior authorization requirements
- pricing*
- coverage status**
* Actual payments to providers are based on "lesser of" payment methodology, which can be found in the Pharmacy Provider Manual. If a NDC displays 'covered,' but doesn't show pricing, ND Medicaid will use the current Wholesale Acquisition Cost price to determine pricing.
** Drugs for newly participating labelers in the Medicaid Drug Rebate Program will appear as ‘not covered’ until the drug shows active in the Centers for Medicare and Medicaid Services quarterly rebate file. Call (800)755-2604 with any questions.
Keep in mind, information contained on this website is not a guarantee of payment. Prior authorization forms and ND Medicaid's preferred drug list can be found on ND Medicaid prior authorization website.
Pharmacy coverage updates
Weight Loss
- Effective Dec. 1, 2023, phentermine, bupropion, naltrexone and topiramate will be covered for weight loss with no prior authorization. Other medications are not covered for weight loss currently.
Diabetes
- InPen will be covered effective Jan. 1, 2024.
- BD and Ulticare will remain as covered insulin syringes. No other insulin syringes will be covered effective Jan. 1, 2024.
Quantity Limits
- Birth control is now allowed for a year supply at a time. Continuous use is allowed.
- Proton pump inhibitors are now allowed with a 90-day supply.
- Hepatitis C medications now require entire course to be dispensed at initial fill.
Over-the-Counter (OTC) medications
- OTC items must be prescribed by an enrolled provider to receive payment from ND Medicaid. This includes recently approved over-the-counter naloxone and birth control.
Discontinued products
- Due to a change in federal regulation, many brand name drugs will be discontinued or have their net price changed so ND Medicaid will no longer be able to prefer certain medications.
- Flovent HFA and Flovent Diskus will be discontinued as of Dec. 31, 2023. Arnuity Ellipta prior authorization has been removed. Please consider moving patients to different product as the generic Flovent HFA will remain nonpreferred.
- Imitrex nasal spray will be discontinued by end of first quarter 2024. Zomig nasal spray does not require prior authorization. Please consider moving patients to a different product as generic Imitrex nasal spray will remain nonpreferred. Note: We expect this will impact several more products in the beginning of 2024.
See current pharmacy coverage policies by navigating to the preferred drug list using the left tabs located on this website. You can also find prior authorization forms and the NDC Drug Lookup tool for coverage there.
The Primary Care Case Management (PCCM) Program ends on Dec. 31, 2023
What does this mean for providers?
Providers will no longer be chosen by members as designated primary care providers for ND Medicaid. Certain services still require an order or referral. Members will be able to seek orders and referrals from enrolled providers. See individual policies for applicable requirements.
The $2 capitation payment will end on Dec. 31, 2023.
What does this mean for members?
Medicaid members who are in the PCCM Program will be enrolled into ND Medicaid’s benefit plan called Fee for Service. Members do not need to do anything and their coverage will not stop. This change starts Jan. 1, 2024.
What is an OLP and what preventive services are covered?
An OLP is an "other licensed practitioner" in ND Medicaid policy language. These are nonphysician practitioners who practice independently. A listing can be found in the General Information for Providers manual under the Other Licensed Practitioner policy chapter.
ND Medicaid covers a variety of preventive services for people of all ages. We now have a "Preventive Services and Management of Chronic Diseases" policy with more coverage information on wellness checks, preventive screenings and more. The policy is currently located in the General Information for Providers manual.
Payment Error Rate Measurement (PERM)
What is PERM?
It is a program that measures and reports an unbiased estimate of the true improper payments in Medicaid and CHIP (Optional Children’s Group). It also 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.
Why is this important to me?
The Centers for Medicare and Medicaid Services and the review contractor, Empower AI, will be sending letters to various ND 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 respond to the records requests in a timely manner. Providers should start receiving the letters sometime in late March or April 2024.
When is this PERM audit going to happen?
The upcoming cycle will review ND Medicaid and CHIP (Optional Children’s Group) payments made in reporting year 2025 for July 1, 2023, through June 30, 2024.
Components of a PERM audit payment rate
Statistical Contractor
- Collects and reviews claims and payment data.
- Ensures completeness and compliance with PERM requirements.
- Payment methodologies and Medicaid vs. CHIP (Optional Children's Group) matched payment.
Eligibility Review Contractor
- Will perform eligibility reviews using data samples selected by statistical contractor to inform the resulting improper payment rate.
- State eligibility policies, systems, processes and case documentation.
Review Contractor
- Will perform data processing and medical reviews on the samples selected by the statistical contractor to inform the resulting improper payment rate.
- State adjudication systems, managed care programs, vendors, third-party administrators, fee schedules, waivers and claim submission policies.
New contact for SFN 447 – Exemption for Submitting Electronic Claims
The SFN 447 form was updated in November 2023 as it should now be sent to Cheryl Nelson in the Medical Services Division. There are three ways to submit your form:
Fax: (701) 328-1544 - ATTN: Cheryl Nelson
Email: chenelson@nd.gov
Mail: Medical Services Division - ATTN: Cheryl Nelson
North Dakota Health and Human Services
600 E. Boulevard Ave., Dept. 325
Bismarck, ND 58505-0250
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