North Dakota ND

ND Medicaid expresses prior authorization as 'Service Authorization' (SA). The shape is POLICY-PER-SERVICE-AREA: ~80 individual service/policy PDFs at hhs.nd.gov/healthcare/medicaid/provider/manuals-and-guidelines, each governing one topic and stating its own SA requirements. The code-level index is the Procedure Code Look-Up Tool (tells you per-CPT/HCPCS whether covered + SA required). The umbrella policy is 'Service Authorizations' (Updated Jan 2026): SAs are service/provider/date-specific, non-transferable, modifiable only by written provider request; no-SA = denial + recoupment. PA request forms are state SFN e-forms: SFN 511 (medical procedure/device), SFN 481 (service limits), SFN 292 (vision), SFN 769 (out-of-state). UM vendor/portal: Acentra Health (ndmedicaid.acentra.com) handles FFS medical + pharmacy SA and the DUR board; pharmacy is state-administered FFS. Authority = ND HHS Medical Services Division (Medicaid agency). Largely FFS; Medicaid Expansion adults are in a single MCO (Sanford Health Plan per state_meta) with their own PA. NOTE: prior finding 450 said BCBSND/Availity for MCO PA — MCO administrator may have changed; left unverified this pass. No login wall on policy PDFs or look-up tool (all HTTP 200, browser-UA fetch). GATHERED: 8 authoritative PDFs ingested to Corsair (document ids 570-577): service-authorizations, medicaid-covered-services, pharmacy-provider-manual (52pp), physician-administered-drugs, out-of-state-services, SFN 511/481/769 forms. All with extracted text.

Medicaid Expansion population enrolled in a single capitated MCO (BCBSND); all other populations (children, pregnant, ABD, duals, foster, 19-20 year olds, medically frail expansion adults) covered as state-administered FFS. PCCM ended 12/31/2023 per HB 1044.

Last award: 2021-06-07. Next due: unknown (presumed renewal or re-procurement around 2025-2026; not confirmed in public sources). Contracts extended through: 2025-12-31 (initial term per OpenMinds; renewals available).

status=partial

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

# ND — learned PA profile (local Qwen synthesis, 2026-05-28) Synth note: map=qwen2.5:7b / reduce=qwen2.5-coder:32b, 10 docs. See [[state_shape_ND]]. Correction pass: WISeR is not applicable to ND — WISeR ("Wasteful and Inappropriate Service Reduction") is a CMS Medicare PA model limited to AZ/NJ/OH/OK/TX/WA; ND does not participate. The model's "WISeR pilot status unknown" line was a template artifact, corrected below. ## 1. How ND requires PA North Dakota's Medicaid program requires prior authorization (PA), referred to as "Service Authorization" (SA) for certain services and supplies. The requirements are detailed in various policy documents, each governing specific service areas or types of care. For instance, medical marijuana requires documentation of medical necessity without step-therapy, while out-of-state services necessitate a written request from the ND Primary Care Physician, a second opinion from an in-state specialist, and assurance that the service is not available locally. Provider-administered drugs also require medical necessity documentation but do not involve step therapy. The criteria for PA vary by service type, with some policies specifying the need for ICD codes and CPT/HCPCS codes to support claims. For example, SFN 481 (2-2026) mandates medical necessity documentation including ICD codes and CPT/HCPCS codes for Medicaid service or drug authorization. ## 2. How ND publishes and reports PA North Dakota publishes its PA requirements through a combination of policy documents and online resources. The primary portal for accessing these documents is the North Dakota HHS website, specifically at hhs.nd.gov/healthcare/medicaid/provider/manuals-and-guidelines. Providers can find approximately 80 individual service/policy PDFs detailing the SA requirements. The state also maintains a look-up tool at hhs.nd.gov/healthcare/medicaid/provider/look-up-tool, allowing providers to search for specific PA codes. The portal is described as "partial," indicating that not all PA requirements are centrally available through this tool. ## 3. ND's CMS-0057-F and PA-reform compliance posture North Dakota's compliance with CMS-0057-F appears in progress but is not fully detailed in the source documents. The state has published several policy documents that align with CMS requirements, such as those requiring medical necessity documentation and specifying PA criteria. There are gaps regarding specific compliance measures. Step therapy is mentioned in some policies (e.g., pharmacy carve-out) but not universally required across all service areas. (WISeR not applicable — ND is not one of the six WISeR-model states.) ## 4. How ND runs its own program North Dakota's Medicaid program operates under a hybrid model. The Medicaid Expansion population is enrolled in a single capitated MCO, Blue Cross Blue Shield of North Dakota (BCBSND), while other populations (children, pregnant women, adults with disabilities, dual eligibles, foster care recipients, 19-20 year olds, and medically frail expansion adults) are covered under state-administered FFS. The pharmacy carve-out directs these services to the state's FFS system. The fiscal agent for the FFS program has transitioned from ACS-Inc to Conduent/Gainwell. Per source documents, the MCO procurement cycle is four years with optional renewals; the last award was June 7, 2021, with contracts extended through December 31, 2025. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Service-specific policies**: North Dakota publishes detailed service-specific policies outlining PA requirements. - **Medical necessity focus**: Across service areas, emphasis is consistently on medical necessity documentation. - **Transitions in fiscal management**: The transition from ACS-Inc to Conduent/Gainwell reflects changes in claims processing under FFS. ### What's Missing/Uncertain: - **Comprehensive PA portal**: The centralized lookup tool is described as "partial." - **WISeR**: Not applicable — ND is not a WISeR-model state. - **Step therapy consistency**: Mentioned in some policies but not universally required. - **Effective dates**: Several documents do not specify effective or revised dates.