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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.

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

RE-ENROLLMENT APPLICATIONS WILL BE PROCESSED IN THE ORDER IN WHICH THEY ARE RECEIVED. PLEASE DO NOT CALL PROVIDER ENROLLMENT (PE) TO INQUIRE ABOUT STATUS. PE STAFF WILL CONTACT YOUR OFFICE IF ADDITIONAL INFORMATION IS NEEDED. PROVIDERS WILL BE NOTIFIED OF RE-ENROLLMENT AND BILLING INFORMATION AS WE APPROACH THE 2ND PHASE OF THE PROJECT, WHICH IS ANTICIPATED FOR 2ND QUARTER 2014. THE DEPARTMENT APPRECIATES YOUR PATIENCE DURING THE TRANSISTION INTO THE NEW MMIS SYSTEM.

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.
  • 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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