Medicaid Provider Enrollment

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The State of North Dakota contracts with Noridian Healthcare Solutions to complete Provider Enrollment for all providers except Qualified Service Providers (QSP). Specific enrollment and revalidation information for QSPs can be found on the QSP webpage.  

 

North Dakota Medicaid provider policies are located at: 

Provider Guidelines, Manuals and Policies | Health and Human Services North Dakota

 

Enrolling in ND Medicaid is a four-step process:

 

Step 1: Search for enrolled providers

 

Prior to completing an application, providers should search the below documents to confirm there is no current enrollment. If a provider is enrolled, do not submit a new application.

 

Step 2: Online application

 

All providers are required to apply for enrollment electronically on the ND Health Enterprise MMIS portal. 

ND Health Enterprise MMIS Web Portal

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  • (Applicable to Groups and Sole Proprietors) IRS Form CP 575 - letter generated from the Internal Revenue Service (IRS) granting providers their Employer Identification Number (EIN); OR, the 147C is a replacement letter from the IRS verifying provider’s Legal Business Name and Tax ID. This letter can be used in place of a CP 575. If unable to locate either of these letters, visit Lost or misplaced your EIN? | Internal Revenue Service
  • Legal Business Name (as shown on IRS documentation)
  • Doing Business As (DBA) name and years doing business under this name
  • (Applicable to Groups and Sole Proprietors) Employer Identification Number (EIN, also known as Tax ID) and begin date (located on the CP 575- IRS letter)
  • License and Certification information (if applicable)
  • National Provider Number (NPI)
  • Drug Enforcement Agency (DEA) number (if applicable)
  • National Council for Prescription Drug Program (NCPDP) number (if applicable)
  • Medicare information (if applicable) - Legal name MUST match as reported to the IRS and PECOS
  • Clinical Laboratory Improvement Amendments (CLIA) number, begin and end date (if applicable)
  • Clearinghouse or Trading Partner information (if applicable)
  • Affiliation information (defined as Individual providers who perform services on behalf of a Group) - active providers and their ND Medicaid Provider Number, NPI and effective date of affiliation to the Group
  • Ownership information (defined as any person with a five percent or more direct or indirect ownership interest)- Name, date of birth, SSN, effective date of ownership
  • Managing/directing employees (defined as a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency) - Name, date of birth, and SSN.
  • Exclusion/Sanction information - ***discrepancies may result in denial or resubmission of application
  • Taxonomy code - Taxonomy codes identify a health care provider by the service they provide and area of specialty.
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Step 3: Completion of application requirements

Individual Enrollment

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Individual Enrollment

Group Enrollment

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Group Enrollment

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Step 4: Submission of application requirements to Noridian

Provider Enrollment Coversheet must be submitted with all applications. Documentation cannot be 

attached to the online application, you must submit them to Noridian by email, fax, or mail. 

 

Email: NDMedicaidenrollment@noridian.com 
Fax: 701-433-5956 - ATTN: NDM Provider Enrollment 
Mail: Noridian Healthcare Solutions  
         Attn: ND Medicaid Provider Enrollment  
         PO Box 6055  
         Fargo, ND 58108-6055  

 

Revalidation

Revalidations are required to be done for all provider records, regardless of provider type, at least every five years.  DME suppliers are required to revalidate every three years.   

Review the revalidation list for providers who have upcoming or past due revalidations.  Click on the list and do a Ctrl F to search for your name.

To expedite the revalidation process, ND Medicaid relies on Medicare screening if the Group or Individual Provider is ACTIVELY enrolled in Medicare. To do so, providers must ensure the below information matches exactly what is in the Medicare record:

  • Individual: Name, NPI, and Social Security number
  • Group: Legal Business Name, Tax Identification number (TIN), Practice Location, and Ownership information 

After the provider confirms the above information matches, the following documents are the only required documents to submit to complete revalidation:

  • Individual: SFN 615 (Medicaid Program Provider Agreement) and PE Coversheet
  • Group:
    • General - SFN 615- Medicaid Program Provider Agreement; and), SFN 1168 (Ownership/Controlling Interest Conviction Information), and PE Coversheet
    • Pharmacy- SFN 1169- Pharmacy Agreement/Medical Assistance Program, SFN 1168 (Ownership/Controlling Interest Conviction Information), and PE Coversheet
    • NEMT- SFN 620- NEMT, SFN 1168 (Ownership/Controlling Interest Conviction Information), and PE Coversheet

If the Group or Individual Provider is NOT ACTIVELY enrolled in Medicare, revalidation is to be completed by following Step 3 and Step 4 above.

Resources

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Resources

Questions? Need Help?

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Questions? Need Help?

Noridian Healthcare Solutions
Phone: (877)328-7098 (toll-free) or (701)328-7098 option 1
Live support 8 a.m. - 5 p.m. CT, Monday - Friday. After-hours voicemail available.