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  • Prior Authorization Request - Sfn 1115 - State Of North Dakota

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Please refer to Pharmacy and Durable Medical Equipment Manuals for current prior authorization requirements. PRIOR AUTHORIZATION REQUEST ND DEPARTMENT OF HUMAN SERVICES MEDICAL SERVICES ND Department.

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Medically necessary covered services may be provided outside of North Dakota if the services are not available within North Dakota and have been prior approved by the department or if the services are provided in an emergency situation.

Your PCP may have you visit first with a North Dakota specialist who will evaluate your health care needs and then make a recommendation to your PCP and ND Medicaid if you need to be referred to an out-of-state provider. ND Medicaid will review the request and either approve or deny the request.

Medicaid's Look-Back Rule North Dakota has a 60-month Medicaid Look-Back Period that immediately precedes one's Nursing Home Medicaid or Medicaid Waiver application date.

Do You Qualify? Medicaid Expansion is available to individuals between 19-64 with household incomes up to 138% of the federal poverty level (FPL). Individuals eligible for Medicare or Supplemental Security Income (SSI) are not eligible for coverage under Medicaid expansion.

Who is eligible for North Dakota Medicaid Program? Household Size*Maximum Income Level (Per Year)1$19,3922$26,2283$33,0644$39,9004 more rows

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232