GENERAL INFORMATIONFOR PROVIDERSNORTH DAKOTA MEDICAIDAND OTHER MEDICAL ASSISTANCEPROGRAMSPublished by:Medical Services DivisionNorth Dakota Department of Human Services600 E. Boulevard Avenue, Dept. 325Bismarck, North Dakota 58505April 2021
ND MedicaidApril 2021TABLE OF CONTENTSSUMMARY OF CHANGES5KEY CONTACTS6AUTOMATED VOICE RESPONSE SYSTEM (AVRS)8PROVIDER ENROLLMENT10PROVIDER INFORMATION16MEDICAID COVERED SERVICES211915(I) MEDICAID STATE PLAN HCBS BEHAVIORAL HEALTH SERVICES26ABORTION29ALLERGY IMMUNOTHERAPY – ALLERGY TESTING30AMBULANCE SERVICES31AMBULATORY SURGICAL CENTER SERVICES33ANESTHESIA SERVICES35BASIC CARE FACILITIES37BREAST AND CERVICAL CANCER DETECTION39CARDIAC REHABILITATION40CHIROPRACTIC SERVICES42COORDINATED SERVICES PROGRAM (CSP)44DENTAL SERVICES47DURABLE MEDICAL EQUIPMENT (DME)48FAMILY PLANNING SERVICES49FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)50FORENSIC EXAMINATIONS AND INTERVIEWS53HEALTH TRACKS EPSDT55HOME HEALTH AND PRIVATE DUTY NURSING59HOSPICE SERVICES63HOSPITAL SERVICES68IMMUNIZATIONS73INDIAN HEALTH SERVICES AND TRIBALLY OPERATED 638 FACILITIES742
ND MedicaidApril 2021IEP MEDICAID SERVICES BILLED BY SCHOOLS76ICF/IID79LAB, RADIOLOGY AND DIAGNOSTIC SERVICES81LOCAL PUBLIC HEALTH UNITS (LPHU)83MEDICAID ELIGIBILITY OF MEMBER85MEDICAID SERVICES RENDERED IN SCHOOLS86MEDICAL NUTRITIONAL THERAPY88MEDICARE COVERAGE90NONCOVERED MEDICAID SERVICES91NON-EMERGENCY MEDICAL TRANSPORTATION94NP, CERTIFIED NURSE MID-WIVES, CNS AND PA100NURSING FACILITIES101OCCUPATIONAL THERAPY104OPTOMETRIC AND EYEGLASS SERVICES109OUT OF STATE SERVICES114PARTIAL HOSPITALIZATION PSYCHIATRIC (PHP) SERVICES118PHARMACY119PHYSICAL THERAPY120PHYSICIAN SERVICES124PRIMARY CARE CASE MANAGEMENT (PCCM)126PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF)131REHABILITATIVE SERVICES132RECIPIENT LIABILITY140RURAL HEALTH CLINICS (RHC)141SPEECH-LANGUAGE SERVICES143STERILIZATION AND HYSTERECTOMY147SUBSTANCE USE DISORDER TREATMENT SERVICES151SWING BED FACILITIES155TELEMEDICINE157THIRD PARTY LIABILITY (TPL)1593
ND MedicaidApril 2021TRANSPLANT SERVICES1614
ND MedicaidApril 2021SUMMARY OF CHANGESThe April 2021 ND Medicaid provider manual updates contain various changes that aredetailed below. While providers should review chapters that are specific to theirspecialty, all enrolled Medicaid providers are responsible to understand and comply withprogram requirements contained in generic chapters such as provider enrollment,provider information, Medicaid eligibility of a member, noncovered Medicaid services,and primary care case management.A new chapter has been added for 1915(i) Medicaid State Plan Amendment Home andCommunity-based Behavioral Health Services.A new chapter has been added for Medicaid Services Provided in Schools.Clarification has been added to the Optometric and Eyeglass Services chapterregarding the requirement for claims to include the NPI, taxonomy and name of theordering practitioner.Providers should carefully review the following chapters for substantive updates:1. Rehabilitative Services2. Substance Use Disorder Treatment Services3. Occupational Therapy4. Physical Therapy5. Speech-Language ServicesThe changes to the Occupational Therapy, Physical Therapy and Speech-LanguageServices chapters are effective for services rendered on or after July 1, 2021 and forservice authorizations effective on or after July 1, 2021. The updates are beingprovided with the April 2021 publication so providers have the opportunity to adjust theirprocesses by July 1, 2021.5
ND MedicaidApril 2021KEY CONTACTSHours for Key Contacts are 8:00 a.m. to 5:00 p.m. Monday through Friday (CentralTime).Provider Enrollment(800) 755-2604(701) 328-4033(701) 328-4030 (fax)Primary Care Case Managementdhsmci@nd.govCoordinated Services ProgramInquiries regarding coordinated servicesprogram members:(800) 755-2604(701) 328-2346Send written inquiries to:Provider EnrollmentMedical ServicesND Dept. of Human Services600 E Boulevard Ave-Dept 325Bismarck ND 58505-0250or e-mail inquiries to:MedicaidCSP@nd.govor e-mail inquiries to:dhsenrollment@nd.govMedicaid Expansion through SanfordHealth Plan(855) 305-5060Call CenterFor questions about member eligibility,payments, denials or general claimsquestions:(701) 328-7098(877) 328-7098Surveillance/Utilization ReviewTo report suspected ND Medicaidprovider fraud and abuse:(701) 328-4024(800) 755-2604or e-mail inquiries to:mmisinfo@nd.govSend written inquiries to:Fraud and AbuseSurveillance/Utilization ReviewMedical ServicesND Dept. of Human ServicesDept 325600 E Boulevard AveBismarck ND 58505-0250Third Party LiabilityFor questions about private insurance,Medicare, or other third party liability:(800) 755-2604(701) 328-2347Send written inquiries to:Third Party Liability UnitMedical ServicesND Dept. of Human Services600 E Boulevard Ave-Dept 325Bismarck ND 58505-0250Or e-mail inquiries to:dhsmed@nd.govor e-mail inquiries to:medicaidtpl@nd.gov6
ND MedicaidApril 2021Service Authorization ContactsBehavioral Health(701) 328-7068 (ph)(701) 328-1544 (fax)Dental(701) 328-4825 (ph)(701) 328-0350 (fax)Durable Medical Equipment(701) 328-2764 (ph)Long Term Care, for Members Under 21Inpatient Psychiatric Services and PRTFs(701) 328-4864 (ph)(701) 328-1544 (fax)Non-Emergency Medical Transportation(701) 328-4312 (ph)Optometry(701) 328-4825 (ph)(701) 328-0325 (fax)Out of State Medical Care(701) 328-7068 (ph)(701) 328-0376 (fax)Pharmacy800-755-2604 (ph)(701) 328-1544 (fax)Service Limits(701) 328-4825 (ph)(701) 328-0377 (fax)Ascend (Long Term Care and Inpatient PsychServices for Members Under 21(877) 431-13881915(i) Servicesnd1915i@nd.govKepro is contracted with ND Department of Human Services to perform serviceauthorization review of certain requests for services and supplies for members effectiveJanuary 1, 2021. More information can be found on the Provider Updates page caid/provider-updates.html7
ND MedicaidApril 2021AUTOMATED VOICE RESPONSE SYSTEM (AVRS)The North Dakota Medicaid Automated Voice Response System (AVRS) permitsenrolled providers to readily access detailed information on a variety of topics using atouch-tone telephone. AVRS options available include: Member Inquiry Payment Inquiry Claims Status Service Authorization InquiryAVRS Access Telephone Numbers (available 24/7)Toll Free: 877-328-7098Local: 701-328-7098Providers are granted access to the Automated Voice Response System (AVRS) byentering their ND Health Enterprise MMIS issued 7-digit provider Medicaid ID number. Asix-digit PIN number is also required for verification and access to secure information.One provider PIN number is assigned to each Medicaid ID number. Providers who havean NPI that is associated with more than one Medicaid ID number must use the PINnumber assigned to the Medicaid ID number used to access AVRS.Touch Tone Phone Entry*9 (nine)0 (zero)FunctionRepeat the optionsReturn to main menuTransfer to Provider Call Center (M-F 8am – 5pm CT)-orLeave voicemail message (after hours, holidays, andweekends)Callers may choose to exit the AVRS at any point to speak with a provider call centercustomer service representative. The call center is available during regular businesshours from 8am to 5pm central time, Monday through Friday, and observes the sameholidays as the state of North Dakota. Providers may leave a voicemail message whenthe call center is not available. Provider voicemail messages will be responded to in theorder received; and except during heavy call times, response will be the followingbusiness day during regular business hours.8
ND MedicaidApril 2021AVRS OptionsSecondary SelectionsOption 1:Member InquiryCallers may select any of the following options: Eligibility/Recipient Liability Primary Care Provider (PCP) Coordinated Services Program (CSP) enrollment Third Party Liability (TPL) Vision Dental Service Authorizations 1915(i) EligibilityOption 2:Payment InquiryRemittance Advice payment information is available for thespecific time frame entered.Option 3:Claims StatusClaim information is available based upon the Member IDnumber entered, including: TCN (Transaction Control Number) Billed Amount Claim Submit Date Date(s) of Service Claim Status (paid, denied, suspended) Paid Amount (if applicable)Option 4:ServiceAuthorizationInquiryService Authorization information is available based uponthe Member ID number entered, including: Service Authorization (SA) Number Date(s) of Service Authorization Status9
ND MedicaidApril 2021PROVIDER ENROLLMENTPROVIDER ENROLLMENT ELIGIBILITYTo be eligible for enrollment, a provider must: Provide services to at least one ND Medicaid eligible member. Meet the conditions in this chapter and conditions of provider agreement (SFN615) regarding the specific type of provider, program, and/or service. Be a provider with a valid license, certification, accreditation or registrationaccording to the state laws and regulations of the state in which services arerendered.Providers that are on the List of Excluded Individuals and Entities (LEIE), System ofAward Management (SAM) or excluded by another State Medicaid Agency will bedenied enrollment.ENROLLINGProviders interested in enrolling with ND Medicaid must complete an online application.The application is located at ome.In addition to the online application, providers must submit a complete packet ofsupporting documentation for the application to be reviewed and processed. Processingdoes not begin until a complete packet of supporting documentation (in addition to theonline application) is received. Do not send Social Security Numbers or EFT informationby unsecure email. Supporting documentation checklists and form packets can be foundon the Provider Enrollment section of the DHS website along with other enrollment andrecords update request rv/medicaid/provider-enroll-app.html.Documents cannot be attached to the online application. They must be submitted by faxor email to: fax to 701-328-4030 ATTN: Provider Enrollment; or email to dhsenrollment@nd.gov.A retroactive enrollment effective date is limited to no more than ninety (90) days* priorto the date a complete application packet is received. Providers must request aretroactive enrollment effective date, when submitting the complete enrollment packet.Providers who have requested a retroactive effective enrollment date may submit claimsfor covered services provided prior to receipt of all required enrollment documents if theprovider met all eligibility requirements at the time the service was provided and only ifappropriate documentation of the services provided is maintained. ND Medicaid may10
ND MedicaidApril 2021consider a retroactive enrollment effective date that exceeds ninety days for situationsinvolving emergent care provided to a member. Retroactive enrollment is not applicableto the 1915(i) program.Medicaid payment is made only to enrolled providers.Once an application is approved, each newly enrolled provider will receive a letter viathe United States Postal Service with enrollment information that includes a 7-digitMedicaid ID and login information to access the web portal (if the security informationsection was completed during the enrollment process). If the security informationsection was not completed during the enrollment process, providers with an approvedapplication can register for web access using the Provider Registration section on theHome page of the MMIS Web Portal. To register for web access, click the “Register”link, enter the 7-digit Medicaid ID and Social Security Number (for individualpractitioners) or Employer Identification Number (for billing groups).ENROLLMENT REVALIDATIONProviders are required to revalidate their enrollments at least once every five (5) years.ND Medicaid will determine revalidation dates and send notifications to the emailaddress(es) associated with the enrollment record. A revalidation roster is updated eachmonth and published on the ND Medicaid website that lists Provider Revalidation Datesthat are due within 90 days of the published tml.The revalidation date also appears in the online provider portal.RESIDENCY PROGRAMAll physicians in a residency program who have been granted a license to practicemedicine in North Dakota by the ND Board of Medical Examiners or have been granteda temporary special license for foreign medical school graduates as outlined in theMedical Practice Act of ND (Chapter 43-17-18.4) must enroll with ND Medicaid in orderto bill for services rendered to members. Residents who are eligible to enroll with NDMedicaid shall not bill using a supervising physician’s NPI.OUT OF STATE PROVIDERSAn “out of state provider” is a provider located more than 50 miles from a North Dakotaborder. All out of state services require service authorization (except in the local tradearea within 50 miles of the North Dakota border or services provided in response to anemergency). Out of state emergency services require a retroactive authorization inorder to receive payment.11
ND MedicaidApril 2021An out of state provider may apply for a retroactive enrollment date for the date ofservice provided to a member. Timely filing applies for claims processing purposes.Providing a claim to provider enrollment for enrollment purposes does not equate tosubmitting a claim for timely filing purposes.A retroactive enrollment effective date is limited to no more than ninety (90) days priorto the date a complete application packet is received. Providers shall indicate, on theenrollment checklist, the desired claim submission date (enrollment effective date).Provider enrollment staff will not approve a date beyond 90 days of receipt of acomplete application packet unless it involves an emergency service provided to amember. If the application involves an emergency service, a copy of the claim andmedical notes must be submitted with the application packet. If not submitted, a datebeyond 90 days of receipt of a complete application will not be approved.Providers interested in enrolling with ND Medicaid must complete an online application.The application is located at ome. Inaddition to the forms indicated in the online application, an Out of State EnrollmentClarification form (SFN 509) is required. The form is available at www.nd.gov/eforms.In addition to submitting the online application and SFN 509, providers who wish toenroll, must submit a complete packet of supporting documentation before theapplication will be reviewed and processed. Social Security Numbers and EFTinformation sent electronically, should only be sent via secure email. Supportingdocumentation checklists and form packets can be found on the Provider ApplicationInformation and Forms page of the ND Medicaid website along with other enrollmentresources: d/provider-enrollapp.html.Documents cannot be attached to the online application. They must be submitted by faxor email to: fax to 701-328-4030 ATTN: Provider Enrollment; or email to dhsenrollment@nd.gov.CHANGES IN ENROLLMENTProviders are responsible for ensuring that enrollment information remains current.Changes that cannot be updated through the provider web portal may be emailed todhsenrollment@nd.gov. Changes that include sensitive information such as socialsecurity numbers, dates of birth, etc., may be sent via secure fax at 701-328-4030, attn.Provider Enrollment.12
ND MedicaidApril 2021To avoid payment delays, notify Provider Enrollment of address or Automated ClearingHouse (ACH) changes in advance.CHANGE IN OWNERSHIPProviders are required to furnish changes in owners who have 5% of more ownershipinterest within 35 days. Refer to 42 Code of Federal Regulation (CFR) § 455.104 formore information. For tax reporting purposes, Provider Enrollment must be notified atleast 30 days in advance of any changes that cause a change in a tax identificationnumber.Providers that are enrolled with both Medicare and Medicaid must ensure that theowners and managing employees match. Discrepancies delay application approvalsand for enrolled providers, may result in payment suspensions.PROVIDER UPDATESProvider updates (affiliations, terminations, EFT, taxonomy, address, name, etc.) mustbe submitted to Provider Enrollment for processing. See the Provider Enrollment sectionof the DHS website for more information on how to request these /medicaid/provider-enroll-app.htmlProvider Enrollment Frequently Asked ATING MEDICAID ENROLLMENTMedicaid enrollment may be terminated by submitting a notice either via email todhsenrollment@nd.gov or via fax to 701-328-4030, Attn: Provider Enrollment. Includename, national provider identifier (if applicable) and the termination date. Terminationwithout cause must be provided in writing and requires 30 days’ advance notice. NDMedicaid may also terminate enrollment under the following circumstances: Breaches of the provider agreement; Demonstrated inability to perform under the terms of the provider agreement; Failure to abide by applicable North Dakota and U.S. laws; or Failure to abide by the regulations and policies of the ND Department of HumanServices or the ND Medicaid program.North Dakota Administrative Code 75-02-05 provides additional information.PROVIDER REQUIREMENTSBy signing the application to enroll as a provider for North Dakota Medicaid, providersagree to abide by the conditions of participation addressed on the provider agreement.13
ND MedicaidApril 2021The Medicaid Program Provider Agreement (SFN 615) is available atwww.nd.gov/eforms. Additional requirements may apply based on the provider type orprovider specialty. Requirements include: No member should be abandoned in a way that would violate professional ethics. Members may not be refused service because of race, color, national origin, ageor disability. Members enrolled in Medicaid must be advised in advance if they are beingaccepted only on a private pay basis. When a provider arranges ancillary services for a member through otherproviders, such as a lab or a durable medical equipment provider, the ancillaryproviders are considered to have accepted the member and they may not bill themember directly.PROVIDER OBLIGATIONSAs a condition to participate in the Medicaid program, the provider agrees to, uponreasonable request, release information needed to support the services billed to NDMedicaid.ND Medicaid is a covered entity under HIPAA and is acting within its authority torequest documentation. Providing the requested documentation is not a HIPAAviolation. 45 CFR §164.506 outlines the uses and disclosures to carry out treatment,payment, or health care operations and 45 CFR § 164.512(d) permits the disclosure ofprotected health information to a health oversight agency (which includes ND Medicaidas a government benefit program).42 CFR § 456.23 outlines ND Medicaid's authority to conduct a post paymentreview. North Dakota Administrative Code 75-02-05-04(2) outlines providerresponsibilities which includes providing documentation upon request. In addition, 42CFR § 431.107(a)(2), requires providers to submit information regarding Medicaidpayments for furnishing services.All ND Medicaid enrolled practitioners are responsible for ensuring services are orderedor rendered within their scope of practice according to state law. ND Medicaidrecognizes there are other professional sources that define the relationship between themember and provider; including current CPT code definitions, current HCPCS codes,ethical standards of practice, accepted professional standards of practice and curr
GENERAL INFORMATION . FOR PROVIDERS. NORTH DAKOTA MEDICAID . AND OTHER MEDICAL ASSISTANCE PROGRAMS . Published by: Medical Services Division . North Dakota Department of Human Services . 600 E. Boulevard Avenue, Dept. 325 . Bismarck, North Dakota 58505 . January 2021
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