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North Dakota Medicaid

Provider Application Information & FormsDeco Line

The information below is for electronically submitted North Dakota Medicaid applications using the new North Dakota MMIS Web Portal. A printable PDF version is linked below for reference/distribution.

The N.D. Department of Human Services is working on the new ND Medicaid claims processing system: ND Health Enterprise MMIS.

The Department has worked on ND Health Enterprise MMIS for many years and has experienced several delays. The Department is carefully reviewing claims payment and testing to ensure ND Health Enterprise MMIS can support claims payment before the final decision is made to complete the transition to the new system.

The Department will keep providers posted on the implementation date that is identified after it is confident that the system will meet critical business requirements.

Providers:

The new MMIS now under development will offer providers a user-friendly self-service web portal that has new features and benefits. 

  • Use the MMIS web portal now to enroll electronically. This is required for all new and existing providers with the exception of Individual Qualified Service Providers (QSPs) and Developmental Disability Providers.
  • Use the MMIS web portal at a later date to directly enter claims, upload batch transactions, and get real-time access to member eligibility, claims status, remittance advice, payment status and claims history.
Need help? Contact Automated Health Systems at 855-238-4848 or ndproviderservices@automated-health.com. Developmental Disability Providers should call 701-328-8983 or toll free 800-755-8529. 

ALL DOCUMENTATION SUBMITTED MUST INCLUDE THE APPLICATION TRACKING NUMBER (ATN) FROM THE ONLINE ENROLLMENT APPLICATION.

Medicaid Providers

  • W9 (August 2013 version) - Required for all billing providers. Name and Tax ID must be exactly as reported to the IRS. The Signer of the W9 must be listed in the Managing/Directing section of the enrollment application.
  • IRS Issued Tax Exempt Letter – Required for all billing providers with tax exempt status.
  • License, certification, accreditation - must be a current, legible copy. Facilities that do not hold licensure must submit a copy of one (1) of your individual providers.
  • ALL Durable Medical Equipment (DME) providers must possess a N.D. Pharmacy License. Legislation (SB 2342) that includes information on licensing requirements.
  • DEA Controlled Substance Registration Certificate (if applicable) - must be a current, legible copy.
  • CLIA Certificate of Compliance (if applicable) - must be a current, legible copy.
  • Proof of Medicare Enrollment - must include your Medicare number.
  • Proof of Liability Insurance - must be a current, legible copy.
  • National Provider Identifier (NPI) - Required for all providers except Transportation, Lodging, Qualified Services Providers (QSP), and Developmental Disability (DD) providers. Submit a copy of the NPI registry from https://nppes.cms.hhs.gov/NPPES/Welcome.do
  • Copy of a Voided Check, Deposit Slip, or Documentation from your financial institution with both routing and account numbers - Required for all billing providers requesting EFT.
  • Ownership/Controlling Interest and Conviction Information (SFN 1168) - Required for all billing providers. The signer of the W9, all State forms (SFN 1168, SFN 615, SFN 1169, SFN 308), all managing employees, and all board members must be listed in Section III of this form. Incomplete forms will be returned and will result in delay of processing your enrollment.
  • Medicaid Program Provider Agreement (SFN 615) - Required for all providers.
  • Contract to Provide Primary Care Case Management Services (SFN 1296) - Required for all primary care physician type providers.
  • Pharmacy Agreement/Medical Assistance Program (SFN 1169) - Required for all Pharmacy providers.
  • Medicaid and Basic Care Assistance Programs Provider Agreement (SFN 308) - Required for all Basic Care providers.
  • Rate Letter/Cost Report - Required for all Rural Health Clinics (RHC), Federally Qualified Health Centers (FQHC), Basic Care, Mental Health, Psychiatric Residential Treatment Facilities (PRTF), Nursing Homes Critical access Hospitals, and Home Health providers.

Out of State (OOS) Providers
All of the above-mentioned documentation as well as:

Transportation Providers

 

Options for Submitting Provider Enrollment Documentation

  • Electronically through a secure link - For those providers that wish to send the required documentation via email, you must request access to a secure link by sending an email to dhsenrollment@nd.gov. Do not email documents to this address. An email will be sent back to you with a link to a secure site to send your documents to the enrollment application.
  • Fax - Providers may fax the required documentation to (701) 328-1544.
  • Standard mail address - Medicaid Provider Enrollment, ND Dept of Human Services, 600 E Boulevard Ave Dept 325, Bismarck ND 58505-0250

MMIS Required Documents Checklist (pdf)

Manual (paper) Provider Enrollment Information

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