Welcome to the North Dakota Medicaid Provider newsletter. We hope this newsletter provides you with important and beneficial information about the North Dakota Medicaid Program. If you have any suggestions for future articles, please send your ideas to dhsmed@nd.gov.
In this edition, you can learn about:
- New COVID-19 vaccine policy,
- Training opportunities to become a Medicaid 1915(i) Home and Community-Based Behavioral Health Services provider,
- Billing telehealth during the public health emergency,
- Program integrity efforts,
- Upcoming 2021 Medicaid-related public meetings and more.
Thank you for being a North Dakota Medicaid provider and serving North Dakota Medicaid members.
COVID-19 Vaccine Information
The COVID-19 vaccine will be available soon in North Dakota. The state has developed a plan on how North Dakotans will be prioritized to receive the vaccine. Find more information here.
North Dakota Medicaid will reimburse providers who are enrolled with the North Dakota Department of Health to administer the COVID-19 vaccine. Providers must also be enrolled with North Dakota Medicaid to receive reimbursement for vaccine administration.
Once the vaccine is publicly available, a list of providers who are able to administer the vaccine will be posted here.
The codes and fees are in the table below. Currently, the vaccine itself is being provided at no cost to providers and patients by the federal government, but North Dakota Medicaid still requires submission of the vaccine code, to ensure the appropriate administration code is being billed for the vaccine given.
Billing Instructions by Claim Type
Clinics/Pharmacies - submit via an 837P (professional claim) using the vaccine CPT code appended with modifier SL along with its correlating administration code.
RHCs/FQHCs/Outpatient Hospital - submit via an 837I (institutional claim) using the vaccine CPT code appended with modifier SL under Revenue Code 0636, the correlating administration CPT code must be billed under Revenue Code 0771. Both the vaccine and administration must be reported on the same claim.
IHS/Tribally Operating 638 Facilities - submit via an 837I (institutional claim) the administration CPT code under Revenue Code 0500.
North Dakota Medicaid new vaccine policy is online here.
If you have any questions regarding COVID-19 administration for North Dakota Medicaid members, email dhsmed@nd.gov.
Update on Medicaid 1915(i) state plan amendment
The North Dakota Department of Human Services, Medical Services Division, began accepting provider enrollment applications for Medicaid 1915(i) Home and Community-Based Behavioral Health Services on November 2, 2020.
Provider Enrollment
Providers are needed for the following services:
Care Coordination, Peer Support, Family Peer Support, Housing Supports, Supported Employment, Supported Education, Pre-Vocational Training, Respite, Training and Supports for Unpaid Care Givers, Community Transition Services, Non-Medical Transportation and Benefits Planning.
A snapshot of required provider qualifications for each of the services can be found on the 1915(i) website here.
The current application draft containing a full description of services and provider qualifications can be found on the 1915(i) website here.
Provider Training
The department is in the process of scheduling the following 1915(i) Provider Trainings:
- Home and Community-Based Settings
- Medicaid Billing and Claims
- Service Authorizations
- WHODAS Assessments
- Care Coordination
- Person-Centered Plan of Care
- Eligibility
If you would like to be notified of the upcoming trainings, please sign up to receive notifications on the 1915(i) website here.
Status of 1915(i) Application
The North Dakota Department of Human Services continues to collaborate with the Centers for Medicare and Medicaid Services (CMS) on approval of the 1915(i) application. You will be informed by the 1915(i) website notification system when CMS approval is received and 1915(i) services can begin.
Billing telehealth during the public health emergency COVID-19
During the public health emergency, some changes/exceptions have gone into effect in order to assist providers in billing for telehealth services. The covered telehealth services must maintain visual or audio contact between the provider and the member. Under this notice, Facebook Live, Twitch, TikTok and similar video communication applications that are public facing, should not be used in the provision of telehealth by covered health care providers.
Here are some items for providers to consider.
- The following CPT/HCPC codes are noncovered telehealth services:
Virtual Check-in: CPT/HCPCS Codes G2010 and G2012.
E-Visits: CPT/HCPCS Codes 99421-99423, 98970-98972 and G2061-G2063
- The CR modifier must be used on a professional claim if the telehealth service is delivered via a non-HIPAA compliant platform.
- The condition code DR must be used on an institutional claim if the telehealth service is delivered via a non-HIPAA compliant platform.
- The GT or 95 modifiers are used if the service is delivered via an interactive audio and video system. The service is billed by the performing provider for real time interaction between the provider and member when the member is located at a different location from the billing provider.
Please review the North Dakota Medicaid COVID-19 Temporary Telehealth Policy that was issued on March 25, 2020 that can be found here.
Claims Corner
Team members from the North Dakota Medicaid Claims Unit would like to share these reminders.
Primary insurance coverage claim submission using North Dakota Health Enterprise Medicaid Management Information System (MMIS) web portal
When entering a claim using the MMIS web portal, providers need to follow one of the claim submission instructions below when there is a primary payor (commercial or Medicare).
When there is primary insurance, providers need to make sure they are choosing 'yes' or 'no' under the other insurance information tab on page 3 and then adding the primary insurance information starting on page 4 under coordination of benefits.
NOTE: Medicare Advantage plans are to be listed under Medicare insurance type.
Web Portal Institutional Claim Form Submission Instructions with primary payor can be found here.
Web Portal Professional Claim Form Submission Instructions with primary payor can be found here.
Paper claim submission
Effective April 15, 2020, North Dakota Medicaid no longer accepts paper claims. See letter here.
All submitted paper claims will be returned if they are not on the exemption list. To request a paper exemption, click here.
Providers need to remember when faxing in attachments of any kind, they need to fax in either the SFN 177 form or confirmation page. Learn more here.
Third-Party billers
The Third-Party Biller policy is online here.
Unified Program Integrity Contractor (UPIC)
North Dakota Medicaid would like to make providers aware that the Centers for Medicare and Medicaid Services (CMS) has selected Qlarant (formerly Health Integrity, LLC) as a Unified Program Integrity Contractor (UPIC). UPIC will work with North Dakota Medicaid to detect, prevent, and proactively deter fraud, waste, and abuse in its programs.
Under CMS or North Dakota Medicaid direction, Qlarant will work in conjunction with or separately from North Dakota Medicaid to deter targeted risks to the integrity of Medicaid programs. These vulnerabilities may result from billing approaches, program changes, or other improper practice applications. The goal is to achieve enhanced FWA detection and prevention across Medicaid programs. The UPICs are required to perform their work in compliance with all federal and state laws and regulations, CMS requirements, and Medicare and Medicaid manuals.
In the coming weeks and months your office may be contacted by Qlarant seeking information for one of their processes. We encourage you and your staff to work with Qlarant directly, but feel free to reach out to Steve McNichols with North Dakota Medicaid should you have any questions or concerns.
Payment Error Rate Measurement (PERM) RY2022
The PERM program measures and reports an unbiased estimate of the true improper payments in Medicaid and CHIP and 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 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.
Review Period: The PERM review period covers payments made from July through June to align with state fiscal years and to provide additional time to complete the cycle before reporting improper payment rates. The upcoming cycle will review Medicaid and CHIP payments made in Reporting Year (RY) 2022 for July 1, 2020 through June 30, 2021.
Statistical Contractor (SC) – The Lewin Group (Lewin): The SC will be collecting state’s claims and payment data, processing the data to ensure completeness and compliance with PERM requirements, and selecting samples. The SC may have questions regarding data differences and changes from last cycle, payment methodologies, and identifying Medicaid versus CHIP matched payments. The SC is also responsible for national and state improper payment rate calculations that are provided to states at the end of each cycle.
Eligibility Review Contractor (ERC) – Booz Allen Hamilton (Booz Allen): The ERC will be performing eligibility reviews on the samples selected by the SC to inform the resulting improper payment rate. The ERC may have questions regarding topics such as state eligibility policies, eligibility systems, eligibility processes, and eligibility case documentation.
Review Contractor (RC) – NCI Information Systems, Inc. (NCI): The RC will be performing data processing and medical reviews on the samples selected by the SC to inform the resulting improper payment rate. The RC may have questions regarding topics such as state claims adjudication systems; managed care programs; vendors; third-party administrators, like Pharmacy Benefit Managers (PBMs); fee schedules; special programs (e.g., waivers); and claim submission policies.
The PERM audit is important to all Medicaid providers because CMS and the review contractor NCI will be sending letters to various Medicaid providers requesting medical records to validate that the service was ordered, provided, documented and billed appropriately.
Please make sure that your release of information/compliance/audit departments are aware and responding to the records requests in a timely manner.
Providers should start receiving the letters sometime in late March or April 2021.
- NCI makes initial calls to providers to verify provider contact information.
- NCI establishes a point of contact with providers and sends record requests. Providers have 75 days to submit documentation.
- NCI makes reminder calls and sends reminder letters on day 30, 45, and 60 until the medical records are received.
- If the provider does not respond, NCI sends a non-response letter on day 75 to the State PERM representative.
- If submitted documentation is incomplete, NCI requests additional documentation.
- The provider has 14 days to submit additional documentation.
- A reminder call is made, and a letter is sent on day 7.
- If the provider does not respond, NCI sends a 15-day non-response letter.
Failure to submit documentation or if the submitted documentation is incomplete, the claim(s) will be considered an error and subject to recoupment.
Questions should be directed to the Medicaid Audit Coordinator at (701) 328-4831 or auditresponse@nd.gov.
Retiring, Closing a Practice or Terminating Enrollment with Medicaid
Per Medicaid’s agreement with each provider found here, medical records shall be maintained for at least seven years after the date of service or as required by 75-02-05-04.2.
Provider records can be audited after a provider retires, closes a practice or terminates enrollment with Medicaid. In these situations, the enrollments are considered inactive. All patient records need to be accessible for seven years from the date of service as ND Medicaid SURS can audit up to six years from the date of service. When there are audit findings and a recovery is necessary, claims cannot be adjusted for inactive providers so a check payment is expected. In the event an inactive provider is selected for an audit and is unable to provide the requested documentation, the claims will be considered unsupported, paid in error and recoverable.
2021 Meeting Dates
Medicaid Medical Advisory Committee Meetings
May 11, July 13, Sept. 14 and Nov. 16 - 5 to 7 p.m. CT.
Money Follows the Person Program Stakeholder Meetings
Feb. 19, May 18, Aug. 17 and Nov. 16 - 1 to 4 p.m. CT.
Autism Spectrum Disorder Task Force Meetings
Feb. 22, May 24, Aug. 23 and Nov. 22 - 1 to 4:30 p.m. CT
North Dakota Medicaid Drug Use Review Board Meetings
March 2, June 2, Sept. 1 and Dec. 1 - 1 to 4 p.m. CT
Look for meeting notices and information on other department-related meetings on the North Dakota Secretary of State's website (under Dept. of Human Services public entity column) OR on the department's website.
Medicaid-related training materials are available for providers
North Dakota Medicaid has various training materials available to providers on submitting claims to the North Dakota Health Enterprise Medicaid Management Information System (MMIS) portal, children services, program integrity effort and other important topics.