Q: Who do I call if I have a question?

A: Start by calling our BCBSND Medicaid Expansion Customer Contact Center at 1-833-777-5779. If your question is related to using the Availity Essentials portal, start by contacting Availity Support Services directly.

Q: What happens if I see a member before I become an enrolled 1915(i) provider?

A: Claims submitted prior to provider enrollment will be denied accordingly. If a claim is denied as complete provider liability (contractual obligation (CO), members cannot be billed.

Q: How do I verify member benefits for this program?

A: See step 3 in the How to get started section above for instruction.

Q: How long do I have to file a new claim?

A: See section Requirements to Submit Claims above.

Q: How do I know if I need to submit a new claim, a voided claim, or a replacement claim?

A: An example of when to submit a new (frequency 1): It is the first initial submission of charges If a provider submitted incorrect patient data such as member name, Unique Member Identifier (UMI or Member ID), or date of birth and the claim rejected as unable to identify a match to the member An example of when to submit a void (frequency 8): A charge needs to be withdrawn An example of when to submit a replacement claim (frequency 7): A change or correction of information needs to be completed.

Q: How long do I have to file a replacement claim?

A: Replacement claims must be submitted within 90 days from the initial/original claim remittance date, exceptions apply for the following: Coordination of Benefits Workers Compensation No-Fault Subrogation Third-Party Payers

Q: How can I ensure my claims are processed timely?

A: To assist in timely filling: Make sure the information submitted is correct and accurate Utilize the correct procedure code for the type of service rendered

Q: How long will it take my claim to process?

A: We ask that providers allow at least 30 days for claim processing. If it has been longer than 30 days, you can call the Customer Service Center for a status update.

Q: What will happen if I submit incorrect information on my claim?

A: The claim may deny or be returned. BCBSND will process a claim according to the information submitted.

Q: My claim is not going through in the Availity Essentials portal, what do I do?

A: Contact Availity Client Services at 1-800-282-4548 for further review of front-end claim submission issues. If Availity is unable to assist you, try contacting the BCBSND Medicaid Expansion Provider Service Center.

Q: Why didn’t you pay the total billed charge I submitted?

A: Contact the Customer Services Center to request more information as reasons may vary. Example: Claims total charge was billed higher than the allowed amount of the service billed.

Medicaid Expansion 1915(i) Providers

Overview

The BCBSND Medicaid Expansion program provides the opportunity to Providers who deliver home- and community-based services to individuals with behavioral health conditions for our ND Medicaid Expansion members. These services support individuals to live safely and successfully in the community of their choice and avoid a higher level of care than they need.

BCBSND began administering services for North Dakota’s Medicaid Expansion program effective January 1, 2022. 1915(i) Providers who have credentialed with the North Dakota Department of Human Services (NDDHS) ND Medicaid program can now participate with BCBSND Medicaid Expansion network program.

Jump to section

How to get started
Contracting and credentialing as a 1915(i) provider
Availity Essentials Provider Portal
Requirements for authorization requests
Billing Requirements
Requirements to submit claims
Claim Corrections and Void Requests
Frequently Asked Questions (FAQ)
Applicable Guidelines
Additional Resources
Questions?

How to get started

1. Enroll as a North Dakota Medicaid 1915(i) provider with the State of North Dakota.

a. Make sure to enroll all affiliated clinics and individual providers who may be rendering services.

b. Enrolled 1915(i) providers choose to offer one or more of the following services: Care Coordination, Respite, Training and Support for Unpaid Caregivers, Non-Medical Transportation, Family Peer Support, Peer Support, Supported Education, Benefits Planning, Pre-Vocational Training, Supported Employment, and Housing Support.

2. Provider groups/agencies also need to enroll in our BCBSND Medicaid Expansion network by contacting our Provider Contracting department at providercontracting@bcbsnd.com.

a. Confirmation from Provider Contracting before proceeding with reviewing eligibility and/or other tasks, is also necessary for this step. See the Contracting and Credentialing section below for more information.

3. Get registered for Availity if you don’t already have an account.

a. Medicaid Expansion requires electronic submission. It is important to register as soon as possible to avoid delays in submissions and payment(s).

b. See section Availity Essentials Provider Portal below.

4. Once enrolled with both DHHS and BCBSND, verify the member’s benefit requirements for eligibility to receive 1915(i) services by calling BCBSND at 701-282-1003 during normal business hours.

a. It is the provider’s responsibility to verify a member’s 1915(i) eligibility. Reasons for this include, but are not limited to, a member being eligible for Medicaid Expansion but not eligible for 1915(i) services. A member may lose eligibility for 1915(i) services during their treatment. It is the provider’s responsibility to verify a member’s 1915(i) eligibility.

5. Verify if the service requires precertification by utilizing PA checkpoint.

a. More information on precertification requirements can be found in the Requirements for Authorization requests section below.

6. Enter the members plan of care into Therap. See Requirement for Authorization below for more details on Therap.

7. Begin submitting claims.

Contracting and credentialing as a 1915(i) provider

Important first steps as outlined above:

The first step is enrolling with ND DHHS.
Once enrolled with DHHS and confirmation is received, you can reach out to the BCBSND Provider Contracting team.

a. This step is required if you want to participate in the BCBSND Medicaid Expansion network as a 1915(i) provider.

b. After initial contact, Provider Contracting will send an email with more information about the contracting process. They will also ask for:

- A copy of the agency W9
- The agency address(es)

Note: A signed agreement by both the provider and BCBSND, does not mean you are ready to see members and/or submit authorizations or claims. Provider Contracting will send a secondary email upon execution with information regarding next steps.

- BCBSND must receive information on individual providers at each agency, from DHHS in order for BCBSND to set up providers accordingly.
- Once the file(s) are received and providers are added to the BCBSND system, an additional email notice of specific provider active enrollment will be sent from prov.net@bcbsnd.com. Once that is received, authorizations and claims can then be filed.

Additional Contracting and Credentialing Guidance:

BCBSND will accept the certification process completed by DHHS in lieu of credentialing with BCBSND.
Credentialing of Peer Support Specialists and Care Coordinators is not required for Medicaid Expansion Network Participation with BCBSND; however, the provider must be enrolled in Medicaid in ND. This enrollment information will be shared by DHHS with BCBSND to ensure the most accurate details are loaded into our system.
Background checks will not be conducted by BCBSND as these provider types fall outside our credentialing policy.

The timeline for the above processes may vary depending on the timeliness and completeness of the documentation received from the provider(s) and ND DHHS.

For provider group/agency contracting questions email providercontracting@bcbsnd.com. For questions relating to individual provider set up, email prov.net@bcbsnd.com.

Availity Essentials Provider Portal

Availity Essentials is a secure online provider portal that can be used to 24/7 to:

Verify member eligibility and benefits for ND Medicaid Expansion members
Request precertification/authorizations
Submit claims and review claim status
Correct and void claims
View electronic remittance advice (835)
View Electronic Funds (EFT) payments
- EFT payments should post the following Wednesday after a claim finalizes.

To use Availity Essentials:

1. Review the Availity Essentials provider portal getting started course.

2. Begin registration on the Availity Essentials provider portal.

Choose a person to be the administrator for your organization.
Sign up as provider who has a National Provider Identification (NPI) number.
- For questions on Availity Essentials registration, contact Availity Client Services at 1-800-282-4548, Monday through Friday, 7 a.m. – 7 p.m.

3. Once registered through Availity Essentials, you will have access to free training and help tips

To access training, log into your Availity Essentials account.
Click on Help & Training or Payer Spaces located on one of the two menu bars.

Through Help & Training or Payer Spaces, the administrator and provider can find training resources to learn how to submit a claim, review the remittance viewer and administrative responsibilities and tasks.
Through Claims and & Payments, the provider Administrator will also need to sign up for payment remittance advice notification and electronic funds transfers (EFT) through transaction enrollment.
The BCBSND Availity Essentials webpage, listed in the Additional Resources section below, also has additional information regarding functionality, and how to search for training materials.

Requirements for authorization requests

For dates of service on/after Jan.1, 2025, the prior authorization requirements for 1915(i) services for home and community services will no longer be required.

However, Plans of Care must be submitted and approved prior to rendering services to BCBSND Medicaid Expansion members.

1915(i) providers will follow the1915(i) DHHS plan “Home and Community-based Services administration of operation" guide located at https://www.hhs.nd.gov/sites/www/files/documents/1915i/ND-24-0017%20Approval.pdf.

Plan of Care and SMART goal requirements

Plan of Care and SMART goal requirement documentation will continue into 2025, to align with the standards outlined by DHHS.

DHHS offer training opportunities to learn about these requirements:

Plan of Care information can be found here:
https://www.hhs.nd.gov/sites/www/files/documents/1915i/therap-presentation-12-2024.pdf
SMART goal and additional trainings can be found here https://www.hhs.nd.gov/1915i/trainings in the recordings and trainings. A few that may be beneficial to you under the “Technical Assistance Calls” section:
- Quality Assurance- Needs, SMART Goals and Services (recording)
- Quality Assurance- Needs, SMART Goals and Services (slides)

Services delivered outside of the administrative guidelines need review for medical necessity prior to administration of services.

More information on 1915(i) guidelines and procedures can be found below in the Applicable Guidelines section.

Once a 1915(i) provider is enrolled with both the DHHS and BCBSND Medicaid Expansion, they will want to ensure they follow the proper steps to submit an authorization/precertification for the service they plan to provide.

This can be done by contacting the BCBSND Medicaid Expansion Customer Contact Center (CCC) for initial instructions on how the authorization process works or referring to the information below.

All 1915(i) services require authorization. This step-by-step process guide will assist providers with how to check if authorization is required, as well as how to submit an authorization for review.

Things to note for precertification/authorization requests:

a. The request should be submitted prior to seeing the member. Retro authorizations are not accepted.

b. Authorizations can only start the date the request is submitted.

- Back dating may occur on an initial plan of care and only for the Care Coordination service, when he initial contact, plan of care completion and authorization submission are within 30 calendar days.

c. The provider’s name on the request should be the agency name, not the individual rendering the service.

d. If the authorization is incomplete and missing information necessary to complete the request, a fax will be sent back to obtain the information to the number listed on the initial authorization request.

e. If you have a question on your request or need the status of your request, call the Utilization Management department by calling 1-800-952-8462.

Plan of Care and SMART goal requirements

Service authorization/precertification requests will not be approved if the plans and goals did not meet the standards outlined by DHHS.

DHHS had offered training opportunities to learn about these changes. Their website https://www.hhs.nd.gov/1915i/trainings keeps a list of recordings and trainings. A few that may be beneficial to you under the “Technical Assistance Calls” section:

Quality Assurance- Needs, SMART Goals and Services (recording)
Quality Assurance- Needs, SMART Goals and Services (slides)

Two main items to include in authorizations are:

An updated plan of care with SMART goals with each new service request. New requests will not be approved without a Plan of Care attached that fully meets the established standard.
- For example, if a new request is submitted for another service provider, a plan of care identifying the current need and goal for that member is required. Please ensure all questions in the SMART goal section are completed for each separate goal identified.
- The Care Coordinator is responsible for the plan of care and will need to work with the accepting agency to provide the plan of care for the request.
Request for the acknowledgment form and the meeting attendees signature page. These forms need to be submitted with the Plan of Care.

The BCBSND Utilization Management (UM) team will request this information and if it is not received, the case will be canceled, and the provider can resubmit the request when the documentation is acquired. This may mean the start date of care changes.

Billing Requirements

1915(i) providers should refer to the policies and/or procedures outlined on the www.bcbsnd.com website as applicable.

Information on the procedural codes, which align with the “Code and Modifier” column on the Service Limits and Codes document is housed on the 1915(i) DHHS website.

*The allowance on a claim is based on the ND Medicaid 1915(i) Fee Schedule in effect on the date of service.

Requirements to submit claims

Claims will be submitted through the Availity Essentials provider portal. Availity Essentials is a secure online portal to submit, review and manage claims.

Claims must:

Be submitted within the appropriate timeframes.
Have the correct member information such as name, date of birth and insurance ID card number.
Be submitted with all required provider data such as, TIN, provider name, NPI, and Medicaid ID number, as applicable.

Claims must be sent to BCBSND within the following timeframes:

Six months from the date of service for members who have only a Medicaid Expansion plan
Six months from the enrollee’s retroactive coverage notification
365 calendar days from the date of service for claims involving third-party liability

Note: New claims should be submitted with a Frequency Type 1: Initial Claim. Claims submitted outside of the timeframes listed above will be denied unless BCBSND or its subcontractors created the error.

Instructions to submit a claim electronically

Availity Essentials is the electronic way to submit, review and manage claims. Your company may have chosen to utilize a clearinghouse for claim submissions, if that is the case, please work with your clearinghouse accordingly.

You must be registered with Payer ID 55891-BCBSND.

To submit a new claim, a claim correction or view claim status, refer to the Availity Essentials webpage.

Through Claims & Payments, the provider Administrator can also sign up for the electronic remittance advice (ERA) notification and electronic funds transfers (EFT) through transaction enrollment. More details on these steps can be found on the BCBSND Availity Essentials resource webpage.

For more information and detailed instructions relating to claims and/or claim status, see Availity Essentials help topics (requires login to Availity Essentials).

Claim Corrections and Void Requests

1915(i) providers may need to correct a claim due to billing errors, by submitting a replacement or void (cancellation) of the previously processed claim. Providers will follow the appropriate guidelines and timeframes to correct claims.

Claim corrections must be:
- Submitted after the original or previously processed claim has finalized.
- Submitted within 90 days from the initial/original claim remittance date.

Providers who submit claims electronically through Availity Essentials will need to correct claims with the appropriate frequency type as indicated.

Frequency Type 7: Replacement claim.

- Submitted within 90 days from the initial/original claim processing date
- This is used to correct data on an initial claim, procedure code, date of service or the addition or removal of charges.
- The original claim number assigned by BCBSND is required.

Frequency Type 8: Void/cancel claim

- To withdraw the claim completely.

Review the Medicaid Expansion Provider Manual for more information on the claims correction process.

Frequently Asked Questions (FAQ)

A: For services rendered on or after 1/1/25, the provider is required to submit a plan of care through Therap for review and approval prior to rendering services.

Prior to 1/1/2025 - 1915(i) providers need to get an authorization prior to providing the service. If authorization is not given prior, the claim will be denied as provider liable, and the provider will not receive payment. If a claim is denied as complete provider liability (contractual obligation (CO), members cannot be billed.

A: An example of when to submit a new (frequency 1):

It is the first initial submission of charges
If a provider submitted incorrect patient data such as member name, Unique Member Identifier (UMI or Member ID), or date of birth and the claim rejected as unable to identify a match to the member

An example of when to submit a void (frequency 8):

A charge needs to be withdrawn

An example of when to submit a replacement claim (frequency 7):

A change or correction of information needs to be completed.

A: You may first want to contact the Medicaid Expansion Contact Center to discuss the claim. If a provider still disagrees with a BCBSND determination on benefits or claims, the decision may be appealed. For 1915(i) providers, this will most likely fall into the post service claim appeal, which could include scenarios such as a claim denying for timely filing.

You would not use an appeal for something that can be done via the correction process, such as adding a procedure code to the claim if it were missed upon original submission.

More information regarding the appeal process and timeframes can be found on the BCBSND Appeals webpage.

Applicable Guidelines

1915(i) providers should understand and utilize these guidelines prior to rendering services. As part of your Plan of Care, all the applicable forms below will need to be completed.