ModifiedNorth Dakota Department of Health & Human ServicesPolicy N/A

Rural Health Clinics

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ND Medicaid coverage, encounter reimbursement, billing, documentation, and claim submission requirements for enrolled Rural Health Clinics and eligible practitioners serving eligible North Dakota Medicaid members.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyRural Health Clinics

Policy CodePolicy N/A

Change TypeAdministrative update

Effective DateN/A

Next Review DateN/A

Key ActionEnsure the servicing and billing provider NPIs are enrolled with ND Medicaid on the date of service.

SourceLink

POLICY UPDATE CHANGES

Claim form information was updated in April 2026.

ADA updates were added throughout the document.

7 yearsRecord retention

180 daysOriginal claim deadline

No authorizationService authorization

All-inclusivePayment structure

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ModifiedNorth Dakota Department of Health & Human ServicesPolicy N/A

Rural Health Clinics

Customize your policy alerts

Sign up for all North Dakota Department of Health & Human Services policy alerts

Know when North Dakota Department of Health & Human Services releases new policies or updates existing guidance.

Monitor payer policy activity

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

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyRural Health Clinics

Policy CodePolicy N/A

Change TypeAdministrative update

Effective DateN/A

Next Review DateN/A

Key ActionEnsure the servicing and billing provider NPIs are enrolled with ND Medicaid on the date of service.

SourceLink

POLICY UPDATE CHANGES

Claim form information was updated in April 2026.

ADA updates were added throughout the document.

7 yearsRecord retention

180 daysOriginal claim deadline

No authorizationService authorization

All-inclusivePayment structure

Coverage and Reimbursement Criteria

General RHC Coverage Requirements

ND Medicaid covers services provided by enrolled Rural Health Clinics (RHCs) that are certificated by the Centers for Medicare and Medicaid Services (CMS). Covered services must meet the following general requirements:

ALL of the following

The RHC is enrolled in ND Medicaid.
The service is medically necessary.
The member is eligible for Medicaid on the date of service.
The service has an approved service authorization, when applicable.

Use the Procedure Code Look-up Tool to confirm whether a procedure code is covered and to identify code-specific requirements, including ordering, referring, or prescribing provider (ORP) requirements, service authorization requirements, and current rates.

Encounter and Immunization Reimbursement

Payment for covered RHC services is based on the applicable encounter and billing rules below.

Encounter reimbursement

Payment to an RHC for covered services furnished to a member is an all-inclusive rate for each encounter.
An encounter is a face-to-face or synchronous telehealth visit with the member during which a qualifying RHC service is rendered.
The encounter rate includes covered services provided by a medical professional and related services and supplies.

Immunizations administered with a medical encounter

The immunization and immunization administration are considered incident to the medical encounter and are not reimbursed in addition to the medical encounter.

Claim Reporting and Same-Day Encounters

Submit RHC claims according to the following reimbursement, service-reporting, revenue-code, and same-day encounter requirements.

Claim reimbursement and service reporting

Submit the claim at the provider's usual and customary charge.
Payment is limited to the lesser of the provider's usual and customary charge or the ND Medicaid-calculated reimbursement.
Effective July 1, 2024, report all services provided during the encounter visit on the claim.
Submit services that do not generate an encounter payment for quality reporting and informational purposes.
Submit a separate claim line for each service with the appropriate revenue code, procedure code, date of service, and the provider's usual charge.

Coding and Billing Requirements

Immunization-only administrationRevenueCovered

0771	Vaccine administration

Immunization drug billingRevenueCovered

0636	Drugs requiring detailed coding

RHC encounter revenue codesRevenueCovered

0521	Clinic Visit by Member to RHC/FQHC
0522	Home Visit by RHC/FQHC Practitioner
0524	Visit by RHC/FQHC practitioner to a member in a covered Part A stay at a skilled nursing facility (SNF)
0525	Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay) of NF or ICF/MR or other residential facility

Additional same-day encounterModifierCovered

59	Distinct procedural service modifier required for an additional same-day encounter after illness or injury

Vaccine for Children supplied vaccinemixedNot Covered

No codes listed

Record retention

Retention periodAt least 7 years after the last date the claim was paid or denied

Timely filing

Original Medicaid primary claim deadlineND Medicaid must receive the claim within 180 days from the date of service

Additional same-day encounter

ModifierModifier 59

When required

Provider Responsibilities

Billing Rule

Provider Enrollment Required

Before providing services, verify that the servicing and billing provider NPIs are enrolled with ND Medicaid on the date of service. Locum tenens servicing providers must also be enrolled and listed on the claim form.

Confirm enrollment for both servicing and billing providers.
For locum tenens providers, verify ND Medicaid enrollment and include the provider on the claim form.
RHC services must be furnished by enrolled providers acting within the scope of their licensure.

Denial Risk

Verify Member Eligibility

Providers are responsible for verifying a member’s eligibility before providing services. Check eligibility through the ND Medicaid MMIS Portal or the Automated Voice Response System at 1.877.328.7098.

Key Definitions

Definition

EncounterA face-to-face or synchronous telehealth visit with the member during which a qualifying RHC service is rendered

Definition

All-inclusive encounter rateA payment structure in which covered services furnished to members are reimbursed at one all-inclusive rate for each encounter

Included servicesEach encounter includes covered services by a medical professional plus related services and supplies

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyRural Health Clinics

Policy CodePolicy N/A

Change TypeAdministrative update

Effective DateN/A

Next Review DateN/A

Key ActionEnsure the servicing and billing provider NPIs are enrolled with ND Medicaid on the date of service.

SourceLink

On This Page

Refer to the Immunizations policy for additional information.

When the only service is an immunization

Bill the immunization administration, but do not bill an encounter.
Bill the administration using Revenue Code 0771 (vaccine administration) with the appropriate CPT code.
Include Revenue Code 0636 (drugs requiring detailed coding) and the appropriate CPT code for the vaccine.
For a vaccine supplied through the Vaccine for Children (VFC) program, ND Medicaid does not pay for the vaccine; ND Medicaid pays only for administration, and the claim must still include Revenue Code 0636 and the appropriate immunization CPT code.
For a non-VFC immunization that is currently covered by ND Medicaid, reimburse the immunization under the Medicaid fee schedule using Revenue Code 0636 and the appropriate CPT code.

See the Telehealth policy for additional information on services rendered via telehealth.

Use the appropriate revenue code for each service; do not submit a vaccine administration code with Revenue Code 0521. Vaccine administration must be submitted with Revenue Code 0771.

Revenue codes for RHC services

Use Revenue Code 0521 for a clinic visit by a member to an RHC/FQHC.
Use Revenue Code 0522 for a home visit by an RHC/FQHC practitioner.
Use Revenue Code 0524 for a visit by an RHC/FQHC practitioner to a member in a covered Part A stay at a skilled nursing facility (SNF).
Use Revenue Code 0525 for a visit by an RHC/FQHC practitioner to a member in an SNF not in a covered Part A stay, or in a nursing facility (NF), intermediate care facility for individuals with intellectual disabilities (ICF/MR), or other residential facility.

Multiple encounters on the same day at one location

Encounters with more than one health professional, or multiple encounters with the same health professional on the same day and at a single location, constitute a single encounter.
When billing more than one encounter for a member on the same day at a single location, bill the correct revenue code for each encounter and include the appropriate diagnosis codes, when applicable, on each claim.
Do not report Modifier 59 merely because the member saw more than one health professional or received multiple services from the same health professional on the same day.
Report Modifier 59 on the Revenue Code 052X claim line only when, after the first encounter, the member suffers an illness or injury requiring additional diagnosis or treatment.

When, after the first encounter on the same day, the member suffers an illness or injury requiring additional diagnosis or treatment

Claim lineReport Modifier 59 on the revenue code 052X claim line

Verify eligibility before each service.
Consult the Member Eligibility Manual for limited coverage categories and other eligibility requirements.

Note

General Coverage Requirements

Confirm all basic coverage requirements before billing. Services must be medically necessary, the provider must be enrolled with ND Medicaid, and the member must be eligible on the date of service.

Confirm provider enrollment.
Confirm medical necessity.
Confirm member eligibility on the date of service.
Confirm any applicable service requirements and authorization requirements. Use the Procedure Code Look-up Tool for coverage, ORP requirements, service authorization requirements, and current rates.
RHC payment for covered services is an all-inclusive rate for each qualifying face-to-face or synchronous telehealth encounter; related covered services and supplies are included.

Note

No Service Authorization Required

No service authorization is required under this policy.

Documentation Required

Retain Complete Records

Maintain complete, legible medical and financial records that fully justify and disclose the extent of services provided and billed to ND Medicaid.

Retain records for at least 7 years after the last date the claim was paid or denied.
Follow the documentation requirements in the Provider Requirements Policy.

Billing Rule

Submit Claims Timely

ND Medicaid must receive an original Medicaid primary claim within 180 days of the date of service.

The timely-filing limit may be waived or extended by ND Medicaid in certain circumstances.
Refer to the Timely Filing Policy for additional information.