county jail medical claims billing

ND Department of Human Services

Medical Services Division

County Jail Medical Claims Billing

October 8, 2012

Member Enrollment FormND Department of Human Services, Medical Services Division 2

Member Dis-Enrollment FormND Department of Human Services, Medical Services Division 3

County Jail Medical Claims Billing Invoice

$30Per ClaimProcessed

$ Amount Paid

For the Service

(using ND Medicaid fee schedule)

+

ND Department of Human Services, Medical Services Division 4

ND Department of Human Services, Medical Services Division 5

SAMPLE

ND Department of Human Services, Medical Services Division 6

SAMPLE

ND Department of Human Services, Medical Services Division 7

SAMPLE

Processing Fee

Direct Questions to: Maggie Anderson, 701-328-1603 or

via email at manderson@nd.gov

Forms Inquiries:Mary Lou Thompson, 701-328-2322 or

via email at mlthompson@nd.gov

Claims Inquiries: Provider Relations, 701-328-4043

ND Department of Human Services, Medical Services Division 8