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North Dakota Medicaid

Provider Application Information and Forms

All providers are required to apply for enrollment electronically on the ND Health Enterprise MMIS portal. Exceptions are HCBS/QSP and NEMT providers.

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

Providers:

ND Health Enterprise MMIS offers 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 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?

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

Medicaid Providers

  • W-9 (Most Current 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.
  • CP 575 Letter - The IRS Form CP 575 is an Internal Revenue Service (IRS) generated letter providers receive from the IRS granting their Employer Identification Number (EIN). A copy of your CP 575 is required to verify the provider or supplier's legal business name and EIN. If you are not able to locate the first EIN letter, you can get a 147C letter from the IRS. This is a different type of EIN verification. Call the IRS at 1-800-829-0115 between the hours of 7 a.m. and 7 p.m in your local time zone. Request a 147C letter when the IRS agent takes your call.
  • 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.
  • 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 service providers (QSP), and developmental disability (DD) providers. Submit a copy of the NPI registry from https://nppes.cms.hhs.gov/NPPES/Welcome.do
  • Electronic Funds Transfer (EFT) (SFN 661) - required for all billing providers requesting Electronic Funds Transfer (EFT).
  • 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. Section II Certification must be completed, signed and dated. If you do not have certification, please indicate NA and sign and date to acknowledge the completion of this section. The signer of the W-9 and all state forms as well as managing employees must be listed in Section III of this form. In addition, facilities that are corporations must submit a list of their board members 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.
  • 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.
  • ALL durable medical equipment (DME) providers must have a ND pharmacy license (legislation SB 2342) that includes information on licensing requirements.
  • 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.

Primary Care Providers (PCP)

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. 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

Provider Enrollment Required Documents Checklist

Manual (paper) Provider Enrollment Information


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