CurrentNorth Dakota Department of Health & Human ServicesPolicy 24-0016

Limitations on Amount, Duration and Scope

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Establishes coverage limits, eligibility requirements, provider qualifications, billing responsibilities, and prior authorization requirements for selected North Dakota Medicaid services.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyLimitations on Amount, Duration and Scope

Policy CodePolicy 24-0016

Change TypeNo material change

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionRequest and receive department prior authorization before providing additional tobacco cessation counseling beyond the stated limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21School-based nursing age limit

4 hoursMedical nutrition therapy limit

2/yearTobacco cessation attempts

4Sessions per quit attempt

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CurrentNorth Dakota Department of Health & Human ServicesPolicy 24-0016

Limitations on Amount, Duration and Scope

Customize your policy alerts

Sign up for North Dakota Department of Health & Human Services Policy 24-0016 alerts

Get alerted when Policy 24-0016 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Establishes coverage limits, eligibility requirements, provider qualifications, billing responsibilities, and prior authorization requirements for selected North Dakota Medicaid services.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyLimitations on Amount, Duration and Scope

Policy CodePolicy 24-0016

Change TypeNo material change

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionRequest and receive department prior authorization before providing additional tobacco cessation counseling beyond the stated limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21School-based nursing age limit

4 hoursMedical nutrition therapy limit

2/yearTobacco cessation attempts

4Sessions per quit attempt

School-based nursing for children with complex medical needs

School-based nursing services are available when all of the following conditions are met.

School-based nursing eligibility

Beneficiary criteria
- The beneficiary is Medicaid-eligible, under age 21, and has complex medical needs.Under age 21
Educational and medical necessity documentation
- The beneficiary has an approved Individualized Education Program documenting the medical necessity for nursing services needed to support access to a free appropriate public education.Approved Individualized Education Program
Provider and billing requirements
- Nursing services are provided by a Registered Nurse who is employed by or under contract through a school, and the school bills North Dakota Medicaid for the nursing services rendered.Registered Nurse; school billing

Licensed addiction counselor services

Licensed addiction counselors may enroll and furnish covered services when all applicable professional-scope conditions are met.

Licensed addiction counselor service eligibility: The practitioner is a licensed clinical addiction counselor, licensed master addiction counselor, or practitioner possessing a similar license in a border state and operating within that state's scope of practice, and furnishes non-ASAM services within the practitioner's scope of practice according to state law.Within scope of practice

ASAM services are not included under this policy.

Medical nutrition therapy

Medical nutrition therapy is covered within the annual limit; additional services require authorization based on medical necessity.

Standard medical nutrition therapy coverage: Medical nutrition therapy is provided by a licensed Registered Dietitian as an evidence-based medical approach to treating a qualifying chronic condition through an individually tailored nutrition plan, and coverage does not exceed four hours per calendar year.4 hours per calendar year

Additional services may be authorized if determined to be medically necessary.

Tobacco cessation counseling

Tobacco cessation counseling is covered within the stated annual and per-attempt limits.

Standard tobacco cessation counseling coverage: Tobacco cessation counseling does not exceed two quit attempts per year, and each quit attempt does not exceed four counseling sessions.2 quit attempts per year; no more than 4 sessions per attempt

Additional services may be approved when medically necessary if the provider requests and receives prior authorization from the department.

ASAM services are outside the services described as furnishable by licensed addiction counselors under this policy.

Licensed addiction counselors may not furnish services outside their scope of practice under applicable state law.

Authorization and Documentation Requirements

Prior Authorization

Additional Nutrition Therapy

Medical nutrition therapy is covered for up to four hours per calendar year. Additional services beyond this limit may be authorized when they are determined to be medically necessary.

Document the medical necessity supporting services beyond the four-hour annual limit.
Obtain additional authorization before providing services beyond the covered limit.

Prior Authorization

Additional Tobacco Cessation Counseling

Additional tobacco cessation counseling may be approved only when medically necessary and the provider requests and receives prior authorization from the department.

Coverage is limited to two quit attempts per year.
Each quit attempt is limited to no more than four counseling sessions.
Request and receive department prior authorization before providing additional counseling.

Documentation Required

IEP Must Document Nursing Medical Necessity

For school-based nursing services, the child must have an approved Individualized Education Program (IEP) that documents the medical necessity for nursing services supporting the child's access to a free appropriate public education.

The child must be under age 21, Medicaid-eligible, and have complex medical needs.
The Registered Nurse must be employed by or under contract through a school.
The school must bill North Dakota Medicaid for nursing services provided by the Registered Nurse.

Documentation Required

Document Services Beyond Limits

Providers must maintain documentation supporting medical necessity for services beyond the annual nutrition therapy limit and for additional tobacco cessation counseling. Tobacco cessation documentation must also support the quit attempt and counseling-session limits and include the department's prior authorization when additional services are provided.

Nutrition therapy: document why services beyond four hours per calendar year are medically necessary.
Tobacco cessation: document medical necessity, the number of quit attempts, and counseling sessions provided.
Retain evidence of prior authorization for additional tobacco cessation counseling.

Denial Risk

Authorization Required Beyond Four Hours

Medical nutrition therapy coverage is limited to four hours per calendar year. Services beyond four hours require additional authorization to be covered, even when the provider determines they are medically necessary.

Additional services may be authorized if determined to be medically necessary.
Do not assume services beyond the annual limit are covered without additional authorization.

Denial Risk

Prior Authorization for Additional Tobacco Counseling

Tobacco cessation counseling is limited to two quit attempts per year, with no more than four counseling sessions per attempt. Exceeding the annual or per-attempt limits requires department approval through prior authorization, and additional services must be medically necessary.

Request and receive prior authorization before exceeding two quit attempts per year.
Request and receive prior authorization before exceeding four counseling sessions for a quit attempt.
Without the required department approval, additional services may not be covered.

Billing Rule

Stay Within Counselor Scope

Licensed addiction counselors may enroll to furnish only non-ASAM services within their scope of practice under state law.

This includes licensed clinical addiction counselors and licensed master addiction counselors.
Practitioners with a similar border-state license must operate within that state's scope of practice.

Limitations on Amount, Duration and Scope

Sign up for North Dakota Department of Health & Human Services Policy 24-0016 alerts

Limitations on Amount, Duration and Scope

Sign up for North Dakota Department of Health & Human Services Policy 24-0016 alerts

Covered Services and Eligibility Requirements

Service Limits and Billing Parameters

Authorization and Documentation Requirements

Policy Context

Key Terms