Provider Updates

Posted 12-31-2025

ND Medicaid is updating the physical therapy, occupational therapy and speech language therapy policies with the following changes. These changes will be effective Feb. 1, 2026. Updated policies will be posted on this date.

Visits to units

To provide billing consistency across services, ND Medicaid is moving from a per visit limit to a per unit limit for physical, occupational and speech language therapies for members 21 and older. We reviewed our claims data to understand how prior visits would translate into units and have changed this for adults in the following ways:

• Physical Therapy – 30 visits --> 60 units
• Occupational Therapy – 30 visits --> 60 units
• Speech Language Pathology – 30 visits --> 30 units

These limits may be exceeded with a service authorization if they are medically necessary. Requests for service above the unit limit will require a service authorization submitted on the SFN 481 as before. An updated version, SFN 481 (2-2026) will be available starting Feb. 1. All service authorization requests made on this date or after must use the new form. Requests made on the previous form will be returned.

CPT® 92507, modifier

Although untimed codes do not include time units in their descriptors, underlying times associated with each CPT® code have been used to determine the value of the evaluation or treatment. CPT® 92507-Treatment of speech, language, voice, communication and/or auditory processing disorder; individual, has a total underlying time of 60 minutes which includes:

• 5 minutes pre-evaluation time
• 50 minutes intra-service time
• 5 minutes immediate post-service time

Effective for dates of service on or after Feb. 1, 2026:

• When less than 35 minutes is spent performing CPT® 92507, modifier -52 (reduced service) must be appended to the claim line and will be reimbursed at 50% of the current fee schedule amount.
• When greater than 90 minutes is spent performing CPT® 92507, modifier -22 (increased service) must be appended to the claim line and will be reimbursed at 120% of the current fee schedule amount.

This change will allow a certain amount of flexibility to spend more time with some patients and less with others while more accurately reimbursing for the time spent delivering the service.

Please refer to Provider Guidelines, Manuals and Policy webpage on Feb. 1 for more information.

Quarterly Coverage Policy Updates

The following Provider Guidelines, Manuals, and Policies have been updated for January 2026. New updates are noted at the bottom of each updated policy.

• Ambulance Services
• Anesthesia Services
• Behavioral Health Rehabilitation Services
• Chiropractic Services
• Dental Case Management
• Immunizations
• Indian Health Services and Tribal Health Programs
• Laboratory and Pathology Services
• Local Public Health Units
• Medication for Opioid Use Disorder
• Non-Emergency Medical Transportation
• Other Licensed Providers
• Out-of-State Services
• Professional and Surgical Services
• Provider Enrollment
• Qualified Residential Treatment Programs
• School-Based Services
• Service Authorizations
• Sign and Oral Language Interpretation
• Third Party Liability

New policies

• Crossover Claims
• Dental Procedures and Nomenclature
• Dental Screening and Assessment
• Facility Calls (Dental)
• Orthodontics
• Place of Service Codes (Dental)
• Teledentistry
• Tooth Numbering System
• Third Party Biller

Posted 12-18-2025

The following drugs will require Service Authorization effective for dates of service on and after January 1, 2026.

Posted 12-11-2025

Provider Enrollment

Flattening forms

ND Medicaid is requesting that providers flatten PDF forms before completing. To learn how to flatten a file, visit Adobe's website.

Posted 12-03-2025

Chiropractic Services Policy updates effective Jan. 1, 2026

We encourage all providers to review the Chiropractic Services Policy, which will take effect on Jan. 1, 2026, to ensure a complete understanding and implementation of these changes. 

Key Policy Updates Include:

1. Modifier -AT Requirement:
   The -AT modifier must now be appended to all Chiropractic Manipulative Treatment (CMT) codes (98940–98942) to indicate active/corrective treatment for acute or chronic subluxation. Claims submitted without this modifier will be denied as non-covered.
2. Diagnosis Reporting – Subluxation Level:
   The level of subluxation must be listed as the primary diagnosis on the claim using the ABK qualifier. This is essential to support the medical necessity of the CMT service.
3. New Documentation Requirements:
   Specific documentation standards have been added for both initial and subsequent chiropractic visits. These include detailed history, physical examination findings, diagnosis, treatment plans, and progress assessments. Proper documentation is critical for justifying billed services and complying with Medicaid requirements.

Posted 11-12-2025

The State of North Dakota sends 1099 tax forms to the billing address in the Medicaid Management Information System (MMIS).

Please confirm that the billing agency on file in MMIS is correct.

To update address information in MMIS, the following forms must be completed:

• Provider Enrollment Coversheet
• SFN 1299 - Group Address Update

Please submit the completed forms to Noridian at NDMedicaidEnrollment@Noridian.com.

Your prompt attention to this matter is appreciated. Thank you!

Posted 10-31-2025

Attention All DME Enrolled Providers:
Effective Nov. 1, 2025, HCPCS codes E1003, E1004, E1005, E1006, E1007, E1008, E1010, and E1012 will be added for coverage. Refer to the manual and powered wheelchair policy for coverage criteria and utilize the Procedure Look-up tool for rates and additional code details.

Posted 10-31-2025

FQHC Dental Billing Effective 01/01/2026

North Dakota Medicaid will require FQHC dental services to be submitted on the ADA claim form (837D) with dates of service on or after 01/01/2026. For dates of service before 01/01/2026, claims must be submitted on the UB-04 (837I).

Providers can utilize the Procedure Code Look-up Tool to verify which dental services are covered.

When billing dental procedures that require a service authorization, the service authorization number must be submitted on the claim.

For questions, please reach out to Alyssa Neis, aneis@nd.gov

Posted 10-2-2025

Attention All DME Enrolled Providers.
Effective Oct. 1, 2025, the following HCPCS codes will require a service authorization.

Posted 10-2-2025

The following Provider Guidelines, Manuals, and Policies have been updated for October 2025. New updates are noted at the bottom of each updated policy.

• 1915(i) Medicaid State Plan Amendment
• Ambulatory Surgical Center
• Covered Medicaid Services
• Electronic Visit Verification
• Federally Qualified Health Centers (FQHCs)
• Gender Affirming Care
• Noncovered Medicaid Services
• Other Licensed Providers (OLPs)
• Provider Enrollment
• Provider Requirements
• Recipient Liability
• Service Authorizations
• Timely Filing

The following are new policies this quarter:

• Community Health Worker
• Community Paramedicine

Posted 9-29-2025

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

Service Authorization requirements have been removed from the following drugs effective Sept. 30, 2025.

 **Brand Remicade will not require prior authorization; however, generic infliximab should be used as an alternative to brand Remicade for adequate reimbursement.

Posted 9-05-2025

Crossover Claim Payment Issue

A MMIS system update on Aug. 14, 2025, inadvertently caused an issue with Medicare crossover claims incorrectly applying patient responsibility. As a result of this issue, claims that should have paid additional dollars were paid at zero.

A fix has been identified and will be completed the night of Sept. 11, 2025. ND Medicaid will reprocess all affected claims. Providers will see their corrected claims on the Sept. 23, 2025, and Sept. 30, 2025 remittance advice.

Contact the call center at (877) 328-7098 with any questions.

Posted 8-25-2025

North Dakota Medicaid continues to receive a large volume of provider appeals for timely filing improper claims submissions. As of Oct. 1, 2025, North Dakota Medicaid will be updating the Timely Filing Policy to include Appeals and Timely Filing Improper Claim Submissions sections to provide clear guidance to providers. North Dakota Century Code section 50-24.1-24(2) states a provider may not request review under this section of the rate paid for a particular service or for a full or partial denial, recoupment, or adjustment of a claim due to required federal or state changes, payment system defects, or improper claims submission.

Improper claim submissions include submissions that fail to meet the necessary requirements or standards set by the department. For timely filing denials, if a claim denies for a violation (for example, no proof of timely filing submitted when submission time limit has been exceeded) of the timely filing policy, and the provider appeals the denial without providing any new information to contest the Department’s finding, this is an improper claim submission which is not appealable. If you received a timely filing denial and had originally filed the claim within the appropriate time limits, the original TCN and RA date are required to be included on your new or adjustment claim (as proof of timely filing) and be resubmitted (not appealed) within 365 days from the date of service (see Timely Filing Policy for retroactive eligibility exceptions).

Effective Oct. 1, 2025, improper claim submission appeals will be rejected and returned to providers.

Contact the provider call center with questions at (877) 328-7098.

Posted 8-21-2025

North Dakota Medicaid continually works to ensure data alignment between our eligibility system and claims processing system. In the event that a member eligibility discrepancy is found between the two systems, North Dakota Medicaid will correct the discrepancy, which means that providers may see claim adjustments or recoupments with a look back period of up to 23 months, if a member was found to be ineligible on the dates of service of claims. Affected members were notified at the time their eligibility ended. Contact the provider call center with questions at (877) 328-7098.

Posted 7-31-2025

MMIS is currently in the process of implementing system-wide security enhancements. As part of these initial efforts, the ability for enrolled providers to make any provider account changes directly within the MMIS system have been temporarily disabled.

At this time, updates or modifications to an enrolled provider’s information will need to be submitted using the appropriate paper change request forms located on the Medicaid provider enrollment webpage.

If you need assistance locating or completing any form, reach out to our Provider Enrollment Call Center.

At this time, the Org Admin can add users and change existing users’ password under their My Account >Manage Users tab.

Noridian Healthcare Solutions
Phone: (877)328-7098 (toll-free) or (701)328-7098  
Live support 8 a.m. - 5 p.m. CT, Monday - Friday. After-hours voicemail available.

Posted 7-11-2025

Fee Schedule Update – The fee schedules for dates of services July 1, 2025, have been posted to the website. Provider rates will receive a 2% 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% 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 2025 RVUs for dates of service on or after July 1, 2025.

Based on the previous calendar 12 month’s claims volume, the new relative value unit adjustments, and a 2% inflationary increase for the first year of the biennium, the resulting conversion factor effective for July 1, 2025, dates of service and after is $36.8442. The previous conversion factor was $36.2591. 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 2% increase in their reimbursement.

The Ambulatory Surgical Center (ASC) conversion factor effective for July 1, 2025, dates of service and after is $31.77 based on the 2.0% inflation increase.

The Anesthesia conversion factor effective for July 1, 2025, dates of service and after is $26.53 based on the 2% inflation increase.

Posted 7-8-2025

The Provider Update that was posted on June 26, 2025, has been updated to reflect the following corrections:

• Service Authorization requirements have been removed from Q5120 and Q5126, effective June 30, 2025.
• Service Authorization requirements have been added to J1748 and Q5122, effective July 1, 2025.

Posted 7-2-2025

The following Provider Guidelines, Manuals, and Policies have been updated for July 2025. New updates are noted at the bottom of each updated policy.

• Abortion
• Behavioral Health Rehabilitative Service
• Family Planning Services
• Forensic Examinations
• Hospice Services
• Occupational Therapy
• Optometric and Eyeglass Services
• Ordering/Referring/Prescribing (ORP) Providers
• Physical Therapy
• Preventive Services, Chronic Disease Management and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
• School Based Services
• Speech Language Services
• Sterilization and Hysterectomy
• Targeted Case Management - Behavioral Health
• Targeted Case Management - Child Welfare
• Targeted Case Management - High - Risk Pregnant Women
• Third Party Liability

The following policies are new policies.

• Claims Guidance
• Clinical Trials (previously part of the Professional Medical and Surgical Services policy)
• Electronic Funds Transfer
• Member Eligibility

Posted 6-26-2025

Effective July 1, 2025 - Steqeyma will be our preferred Ustekinumab product. Members currently on Stelara will need to transition to Steqeyma. Step therapy criteria will also be updated for categories where Ustekinumab is indicated. Please see the Preferred Drug List for details.

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

Service authorization requirements have been removed for the following drugs, effective June 30, 2025.

Posted 6-23-2025

Attention Providers: On Dec. 29, 2022, the Consolidated Appropriations Act, 2023 (CAA, 2023; P.L. 117-328) was enacted. The Centers for Medicare & Medicaid Services (CMS) issued State Health Official (SHO) letter # 24-003 to provide guidance on requirements and expectations for compliance with Division H, Title V, Section 5123 of the CAA, 2023, entitled “Requiring Accurate, Updated, and Searchable Provider Directories.”

Effective July 1, 2025, each public, searchable, Provider Directory must include, at a minimum, the following information for each provider:

• The name(s) of the provider;
• The specialty of the provider;
• The address(es) at which the provider provides services;
• The telephone number(s) of the provider;
• Information regarding the following:
  • The provider’s cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or by a skilled medical interpreter who provides interpretation services at the provider’s office;
  • Whether the provider is accepting new Medicaid patients and whether the provider is accepting new CHIP patients;
  • Which accommodations the provider’s office or facility has provided for individuals with physical disabilities, including offices, exam rooms, and equipment;
  • The internet website of such provider,
    • If no website, NA must be entered
  • Whether the provider offers covered services via telehealth.

The North Dakota MMIS Web Portal has been updated to capture the required fields located under General Information, Service Information.

To complete processing of enrollment records that were in a pending status prior to the MMIS update June 13, 2025, default values were assigned for the following;

• Accepting New Patients – Yes
• Provides Telehealth - No
• Website – NA
• Hours of operation -Monday – Friday 9am – 5pm

To make updates to Service Information, providers are to utilize the Provider Enrollment Coversheet which has been updated to capture the required information. During revalidation or reactivation, providers will need to confirm the Service Information on the Provider Enrollment Coversheet. Provider Enrollment Coversheets are to be submitted to Noridian by email at NDMedicaidenrollment@noridian.com or by fax 701-433-5956 ATTN: NDM Provider Enrollment.

Posted 6-23-2025

Medicare Fraud Scheme Involving Phishing Fax Requests

On Friday, June 20, 2025, the Centers for Medicare & Medicaid Services (CMS) posted the following warning to its website about an emerging fraud scheme:

Alert: Medicare Fraud Scheme Involving Phishing Fax Requests 
CMS has identified a fraud scheme targeting Medicare providers and suppliers. Scammers are impersonating CMS and sending phishing fax requests for medical records and documentation, falsely claiming to be part of a Medicare audit.

Important: CMS doesn’t initiate audits by requesting medical records via fax. Protect your information. If you receive a suspicious request, don’t respond.

If you think you got a fraudulent or questionable request, work with your Medical Review Contractor to confirm if it’s real.

Posted 6-17-2025

Pharmacy Drug and Diabetic Supply Coverage Updates

Posted 5-1-2025

The following Provider Guidelines, Manuals, and Policies have been updated for May 2025. New updates are noted at the bottom of each updated policy.

• Basic Care Facilities
• Behavioral Health Rehab
• Institutions for Mental Disease
• Nursing Facilities
• Occupational Therapy
• Ordering/Referring/Prescribing Providers
• Physical Therapy
• Physician Administered Drugs
• Professional Medical and Surgical Services (previously Physician Services)
• Speech Language Pathology
• Substance Use Disorder Treatment Services
• Swing Bed Facilities
• Transplant Services

Now Live: ND Medicaid Procedure Code Look-up Tool

We’re excited to announce the launch of our new Procedure Code Look-Up Tool. This web-based feature was designed to streamline your workflow by allowing you to search by CPT^©, CDT^©, or HCPCS code to provide at-a-glance information on coverage, current rates, telehealth applicability, service authorization information, claim requirements, and more.

As part of this launch, the following Excel and PDF files have been removed from the website.

Provider Guidelines, Manuals, and Policies  

• Codes Requiring Service Authorization   
• Codes Requiring Ordering, Referring, or Prescribing NPI  
• CDT Codes Requiring Tooth Number/Quadrants
• Telehealth Approved Services

Durable Medical Equipment Providers

• DME Purchase Code Limits and Restrictions
• DME Rental Code Limits and Restrictions

Posted 4-11-2025

Help promote upcoming Medicaid virtual listening session on May 6

As a trusted provider who works directly with Medicaid members, North Dakota Health and Human Services (HHS) would like your help to raise awareness about an upcoming Medicaid virtual listening session.

We want to gather feedback and hear lived experiences to help improve Medicaid for its members and create a strong, member-led advisory committee.

Who should attend?

• Current or former Medicaid members and their family members
• Caregivers of Medicaid members

Details
Tuesday, May 6
3 to 4:30 p.m. CT
Virtual by Microsoft Teams
Listening session agenda

Help spread the word 
We’ve created a partner toolkit that you can use to promote the listening session.

• Flyer: Print and hang up where Medicaid members will see the flyer.
• Social media: Share the graphic and copy on your social channels.

The Justice Well Program is partnering with HHS to host this listening session and other opportunities for members to share their thoughts on ND Medicaid including a member survey opening on May 1.

Thank you for your help in supporting the advancement of strong, stable, healthy families and communities, an HHS strategic priority.

Posted 3-28-2025

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

Attention Behavioral Health Rehabilitative Services Providers:

Effective for dates of service May 1, 2025 and after, ND Medicaid will deny all 837P transactions (professional claims) that that do not contain the ordering/referring/prescribing (ORP) provider’s individual National Provider Identifier (NPI) for all behavioral health rehabilitative services (listed below).

• Screening, Triage, and Referral Leading to Assessment*
• Behavioral Assessment
• Crisis Intervention*
• Behavioral Intervention
• Individual and Group Counseling
• Behavioral Health Counseling and Therapy
• Intensive In-home for Children
• Nursing Assessment and Evaluation
• Skills Training and Integration
• Assessment for Alleged Abuse and/or Neglect and Recommended Plan of Care (formerly known as Forensic Interview)*

*These services may be ordered by the rendering provider.

Screening, triage, and referral leading to assessment; crisis intervention; and assessment for alleged abuse and/or neglect and recommended plan of care may be ordered by the rendering provider, due to the need for immediate care. These are the only behavioral health rehabilitative services that may be self-ordered.

The behavioral health rehabilitative services policy will be updated to address these requirements and published on May 1, 2025.

The ORP Providers policy will be updated and published on May 1, 2025 to align with the requirement for all behavioral health rehabilitative services to have an order/referral. The following providers will be added to the list as allowable ORP providers for screening, triage, and referral leading to assessment; crisis intervention; and assessment for alleged abuse and/or neglect and recommended plan of care.

• Licensed baccalaureate social workers (LBSW)
• Licensed master social workers (LMSW)
• Licensed exempt psychologists
• Licensed associate professional counselors (LAPC)
• Registered nurses (RN)
• Behavior modification specialists (BMS)
• Behavior analysts (BA)

Stay tuned for an announcement on a new procedure lookup tool coming soon for ND Medicaid providers.

The ND Medicaid provider call center is available to answer questions about this requirement at (877) 328-7098.

Posted 3-18-2025

A MMIS update was completed on 03/13/2025 to edit professional claims billed with Telehealth places of service 02 and 10. An error was discovered, causing claims to be denied incorrectly and indicating a missing/invalid/incomplete place of service. We have corrected the error, and the department will adjust any denied claims.

A MMIS update was completed on 03/13/2025 to edit against invalid provider taxonomy codes. If you receive the following denial: 16/N255-Missing/incomplete/invalid billing provider taxonomy, please ensure claims are billed with the correct taxonomy. If your taxonomy needs to be updated, please submit SFN 1302. Once completed, you can email the form to NDMedicaidEnrollment@Noridian.com.

Posted 2-19-2025

Provider Enrollment has added a monthly Medical Provider Enrollment data dashboard that provides the workload summary and processing times for applications. The information can be found on HHS data dashboards webpage under Provider Enrollment.

Posted 2-5-2025

Effective immediately, the codes listed on the Drug tab and Acentra tab of the Codes Requiring Service Authorization spreadsheet do not require Service Authorization for Medicaid members who have Medicare primary and is a service covered by Medicare.  

Posted 1-30-2025

Attention Medicaid Providers - The State of North Dakota is receiving a large volume of returned 1099 tax forms due to incorrect addresses. For your reference, your agency’s 1099 is sent to the billing address on file in MMIS. To update address information in MMIS, the following forms must be completed:

• Provider Enrollment Coversheet
• SFN 1299 - Group Address Update

Please submit the completed forms to Noridian at NDMedicaidEnrollment@Noridian.com.

Your prompt attention to this matter is appreciated.

Updated Provider Enrollment Application Requirements (this does not pertain to QSP or DD Providers)
Effective March 1, 2025, providers are to use the newest version of the Application Requirements located on the Provider Enrollment webpage. If old versions are submitted after March 1, 2025, Noridian will send the Provider a RFI directing them to use the new forms.

Posted 1-27-2025

Effective Jan. 1, 2025, HCPCS Code G2211 - visit complexity E/M add-on will be reimbursed at $0.00. This will appear as a CO-45 on the remittance advice, and the member may not be billed.        

Posted 1-16-2025

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

Posted 1-15-2025

Attention DME insulin pump providers: Effective Jan. 15, 2025, ND Medicaid will cover insulin pumps for insulin-dependent Type 2 diabetics who meet the policy’s coverage criteria.

Provider policy updates: The following policies were updated on the Provider Guidelines, Manuals, and Policies webpage. See the bottom of the policy for the details of the updates made.

• Hospital Services
• Psychiatric Residential Treatment Facility

Posted 1-10-2025

Attention DME providers: Please be advised that as of Jan. 1, 2025, the Purchase Limits and Restriction and the Rental Limits and Restriction policies have been updated.

• The Purchase Limits and Restrictions policy now includes 158 HCPC codes marked with a bold, underlined "No" in the service authorization column, indicating these codes no longer require prior authorization.
• The Rental Limits and Restrictions policy now includes 158 HCPC codes marked with a bold, underlined "No" in the service authorization column, indicating these codes no longer require prior authorization.

Posted 1-6-2025

Effective Jan. 1, 2025, North Dakota Medicaid is changing targeted case management services for individuals with a serious mental illness (SMI) or serious emotional disturbance (SED). The new service is called targeted case management for individuals with behavioral health conditions. Here is what is changing:

• Expanding individuals who are able to access targeted case management services by including individuals who have a diagnosis of a substance use disorder (SUD) only. Prior to this change, individuals with an SUD needed to have another cooccurring mental disorder in addition to the SUD to qualify to receive the services. Individuals must still demonstrate functional impairment to qualify to receive the services.
• Modifying agency and individual provider qualifications, to require that supervisors of case managers have experience with case management but allow for individual case managers who have a bachelor’s degree to provide the service, even if they do not have case management experience.

Updated targeted case management for individuals with behavioral health conditions policy. This policy is located on the main Medicaid coverage policies webpage under Targeted Case Management.  

Find updated provider enrollment documents on the Provider Enrollment webpage.  

Posted 1-3-2025

The following Provider Guidelines, Manuals, and Policies have been updated for January 2025. New updates are noted at the bottom of each updated policy.

• Ambulance Services
• Anesthesia Services
• Behavioral Health Rehabilitative Services
• Home Health
• Immunizations
• Local Public Health Units
• Medicare Coverage
• Non-Emergency Medical Transportation
• Out of State Services
• Provider Enrollment
• Recipient Liability
• School Based Medicaid
• Service Authorizations
• Sign and Oral Language Interpreter Services
• Substance Use Disorder Services
• Telehealth
• Third Party Liability

The following policies are new policies.

• Lab Services
• Private Duty Nursing