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