North Dakota - Home Health Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In North Dakota, Home Health Services provide part-time or intermittent skilled nursing care, physical, occupational, or speech therapy, and home health aide services to patients in their residences. These services must be ordered by a physician and delivered under a strictly monitored plan of care. The North Dakota Department of Health and Human Services (ND HHS) Health Facilities Unit is responsible for licensing these agencies and ensuring compliance with state and federal standards.

The single biggest structural barrier to entry for a new Home Health Agency in North Dakota is obtaining Medicare Certification (Title XVIII). While North Dakota explicitly repealed its Certificate of Need (CON) requirement for home health agencies in 1995—meaning the state does not artificially cap the number of licenses—agencies must still meet the rigorous federal Conditions of Participation to bill Medicaid for skilled services. Because state survey backlogs can delay this process, new agencies typically must secure certification through a CMS-approved accrediting organization before they can successfully enroll in the ND MMIS Health Enterprise Provider Portal.

1. Service Definition and Scope

In North Dakota, Home Health Services are defined as skilled, intermittent clinical care provided to individuals in their place of residence. The core of the service is skilled nursing combined with at least one other therapeutic service, designed to treat an illness or injury rather than provide long-term custodial care.

Services must be medically necessary, ordered by a physician, and guided by a formal plan of care. Continuous private duty nursing or non-medical companion care falls outside the scope of a standard Home Health Agency license and is governed by separate Medicaid waiver or Qualified Service Provider (QSP) rules.

• Statutory Definition: N.D. Century Code 23-17.3-01 defines a home health agency as a public or private agency providing skilled nursing and therapeutic services.
• Skilled Nursing: Must be provided by or under the direct supervision of a North Dakota-licensed Registered Nurse (RN).
• Therapeutic Requirement: Agencies must offer skilled nursing plus at least one additional qualifying therapy, such as physical therapy, occupational therapy, speech therapy, or medical social services.
• Home Health Aide Services: Permitted under NDAC 33-03-10.1-15 when supervised by an RN or appropriate therapist, providing personal care directly tied to the medical plan of care.
• Intermittent Standard: Care must be provided on a part-time or intermittent basis, meaning visits are episodic rather than continuous shift care.

2. Regulatory and Oversight Agencies

The primary regulatory body for home health in North Dakota is the Department of Health and Human Services (ND HHS). Within this department, the Health Facilities Unit handles state licensure applications, conducts onsite inspections, and acts as the state survey agency for CMS.

For Medicaid billing and enrollment, the ND HHS Medical Services Division oversees the program, utilizing the ND MMIS Health Enterprise system to process provider applications and claims.

• Licensing Authority: ND HHS Health Facilities Unit (https://www.hhs.nd.gov/health/regulation-licensure-and-certification/health-facilities-unit/home-health-agencies) issues state licenses and conducts surveys.
• Medicaid Authority: ND HHS Medical Services Division (https://www.hhs.nd.gov/healthcare/medicaid) administers the state Medicaid program and sets reimbursement policy.
• Federal Oversight: Centers for Medicare & Medicaid Services (CMS) (https://www.cms.gov) enforces the federal Conditions of Participation (42 CFR Part 484).
• Enrollment Portal: ND MMIS Health Enterprise Provider Portal (https://mmis.nd.gov/portals/wps/portal/ProviderEnrollment) processes all Medicaid provider applications and revalidations.

3. Gatekeeping Prerequisites: Who Can Even Apply

North Dakota operates an open-market system for Home Health Agency licensure. The state explicitly repealed its Certificate of Need (CON) requirement in 1995 (S.L. 1995, ch. 254, § 6). There are no county sponsorship requirements, closed network moratoria, or mandatory Request for Proposal (RFP) procurements blocking initial state licensure.

However, to enroll as a Medicaid provider for these skilled services, agencies face significant structural prerequisites. They must secure Medicare Certification, which serves as the federal gatekeeper. Additionally, while traditional Medicaid operates on a Fee-for-Service (FFS) basis without managed care lockouts, serving the Medicaid Expansion population requires contracting with the state's single designated commercial carrier.

• Certificate of Need (CON): None exists; explicitly repealed in North Dakota under NDCC 23-17.3-03, allowing open application for licensure.
• Medicare Certification: Required as a structural prerequisite for Medicaid enrollment to bill for skilled home health services; agencies must meet 42 CFR Part 484 standards.
• Accreditation Deeming: Due to state survey backlogs, new agencies typically must achieve Medicare certification through a CMS-approved accrediting organization (ACHC, CHAP, or The Joint Commission).
• Business Registration: Applicants must register their business entity with the North Dakota Secretary of State prior to applying for a state license.
• Medicaid Expansion Carve-Out: While traditional Medicaid is FFS, serving the Expansion population (adults aged 19-64) requires securing a contract with the state's single designated managed care carrier.

4. Licensure and Certification Requirements

Operating a Home Health Agency in North Dakota requires a state license issued under NDAC 33-03-10.1. The process involves submitting an initial application to the ND HHS Health Facilities Unit, followed by an onsite evaluation to ensure compliance with minimum operational and clinical standards.

Licenses must be renewed annually. If an agency is Medicare-certified, the state survey agency or the accrediting body will conduct periodic recertification surveys to ensure ongoing compliance with both state administrative rules and federal Conditions of Participation.

• Licensure Rule: Governed by North Dakota Administrative Code (NDAC) Chapter 33-03-10.1.
• Application Form: Submitted via the ND HHS Health Facilities Unit, requiring detailed ownership, operational disclosures, and the prescribed fee.
• Initial Survey: The department or its authorized agent conducts an onsite evaluation before issuing the initial license, as mandated by NDCC 23-17.3-04.
• Annual Renewal: Licenses must be renewed annually, with the agency submitting a renewal application to maintain active status.
• Change of Ownership (CHOW): Agencies must notify the department in writing at least 30 days in advance of any transfer or change of ownership per NDAC 33-03-10.1-03(9).

5. Medicaid Provider Enrollment

Once licensed and Medicare-certified, agencies must enroll in North Dakota Medicaid using the ND MMIS Health Enterprise Provider Portal. The state utilizes a centralized electronic enrollment process that validates licensure, NPI, and ownership data against federal databases.

Agencies must enroll as an institutional/group provider and complete a Trading Partner Agreement if they intend to exchange electronic data directly with the state's MMIS.

• Enrollment System: ND MMIS Health Enterprise Provider Portal (https://mmis.nd.gov/portals/wps/portal/ProviderEnrollment).
• Provider Type: Must select the specific Home Health Agency provider type and corresponding taxonomy codes during the MMIS application.
• NPI Requirement: Must obtain and provide an Organizational (Type 2) National Provider Identifier (NPI) linked to the agency's legal business name.
• Trading Partner Agreement: Required for any billing provider or clearinghouse exchanging electronic data (EDI) directly with ND Medicaid.
• Application Timeline: Standard portal approval typically takes 30 to 45 business days after a complete and accurate submission.
• Revalidation: Medicaid providers must revalidate their enrollment at least every five years through the MMIS portal to maintain active billing privileges.

6. Staffing, Training and Background Checks

North Dakota home health agencies must employ qualified clinical staff, led by a nurse executive or clinical director. The state mandates strict adherence to professional licensing board standards for all skilled practitioners, ensuring that only qualified individuals deliver care.

Background checks are a critical component of the hiring process. High-risk provider types and personnel with direct patient access are subject to criminal history record checks, including fingerprinting through the North Dakota Bureau of Criminal Investigation (BCI).

• Clinical Leadership: Must designate a qualified nurse executive or clinical manager (typically an RN with home health experience) to oversee all patient care.
• Nursing Staff: Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) must hold active, unencumbered licenses from the North Dakota Board of Nursing.
• Therapy Staff: Physical, occupational, and speech therapists must be licensed by their respective North Dakota professional boards.
• Home Health Aides: Must complete a state-approved training and competency evaluation program as required by 42 CFR Part 484 and NDAC 33-03-15-09.
• Background Checks: Mandatory Bureau of Criminal Investigation (BCI) fingerprint tracking sweeps are required for applicable high-risk staff and agency owners.
• Basic Certifications: Direct care staff must maintain active CPR and Basic Life Support (BLS) certifications at all times.

7. Documentation, Policies and Records

Agencies must maintain comprehensive clinical records and operational policies that comply with both NDAC 33-03-10.1 and Medicare Conditions of Participation. Documentation must definitively prove that services are medically necessary, ordered by a physician, and delivered according to a specific plan of care.

Agencies are also required to implement a Quality Assessment and Performance Improvement (QAPI) program to continuously monitor, evaluate, and improve patient outcomes and safety.

• Plan of Care: Every patient must have a written plan of care established, signed, and periodically reviewed by a physician.
• Clinical Records: Must maintain a centralized clinical record for each patient containing comprehensive assessments, care plans, clinical notes, and discharge summaries.
• QAPI Program: Must develop, implement, and maintain an effective, data-driven Quality Assessment and Performance Improvement program.
• Patient Rights: Must provide written notice of patient rights and responsibilities prior to the initiation of care, documenting the patient's receipt of this information.
• Reporting Changes: Must notify ND HHS in writing within 30 days of any change in administrative staff or the nurse executive per NDAC 33-03-10.1-03(10).
• Record Retention: Clinical records must be retained for the period mandated by state law and federal regulations, typically 5 to 6 years post-discharge.

8. Billing, Rates and Claims

North Dakota Medicaid reimburses Home Health Services primarily on a Fee-for-Service (FFS) basis for the traditional Medicaid population. Claims are submitted electronically through the ND MMIS using standard institutional claim formats.

Reimbursement rates are established by the ND HHS Medical Services Division and are published in the state's Medicaid fee schedules. Services must be prior-authorized when they exceed basic benefit limits or involve specific extended therapies.

• Claim Format: Electronic claims must be submitted using the HIPAA-compliant 837I format or via the MMIS direct data entry portal.
• Fee Schedule: Rates are published on the ND HHS Medicaid Provider fee schedule page and are updated annually or as legislatively directed.
• Prior Authorization: Certain extended therapies or home health aide hours beyond the initial intermittent threshold require prior approval from ND Medicaid.
• Electronic Visit Verification (EVV): Personal care and home health aide services may be subject to EVV requirements under the 21st Century Cures Act to validate visit location and duration.
• Third-Party Liability (TPL): Medicaid is the payer of last resort; agencies must bill Medicare or private insurance before submitting claims to ND Medicaid.

9. Approval Sequence and Timeline

The pathway to becoming a fully billing Medicaid Home Health Agency in North Dakota is sequential and can take 6 to 12 months. It begins with business formation and state licensure, followed by the lengthy Medicare certification process, and concludes with Medicaid enrollment.

Because the state survey agency often faces backlogs, agencies frequently utilize deemed status accreditation to expedite the Medicare certification step, which is typically the longest phase of the sequence.

• Step 1: Business Entity Registration: Register with the ND Secretary of State and obtain an EIN and Type 2 NPI (1-2 weeks).
• Step 2: State Licensure Application: Submit the initial application and fee to ND HHS Health Facilities Unit (30-60 days for review and initial survey).
• Step 3: Medicare Certification/Accreditation: Undergo a survey by an accrediting body (ACHC, CHAP) or the state survey agency (4-9 months).
• Step 4: CMS Tie-In: Receive the CMS Certification Number (CCN) from the federal Medicare Administrative Contractor (MAC) (30-60 days).
• Step 5: Medicaid Enrollment: Submit the application via the ND MMIS Health Enterprise Portal (30-45 business days for approval).

10. Common Denials and Survey Findings

Applications and surveys are most frequently delayed or denied due to incomplete documentation, failure to meet strict clinical leadership requirements, or non-compliance with federal Conditions of Participation during the initial survey.

During state and federal surveys, deficiencies often center around inadequate care planning, failure to follow physician orders, and insufficient supervision of home health aides by registered nurses.

• Application Denial: Incomplete ownership disclosures or failure to pass BCI background checks for key personnel.
• Survey Deficiency: Inadequate or missing physician signatures on the established Plan of Care within required timeframes.
• Survey Deficiency: Failure of the RN to conduct and document the required supervisory visits for home health aides every 14 days.
• Survey Deficiency: Incomplete comprehensive assessments (OASIS data) or failure to complete them within the required federal timeframes.
• Enrollment Rejection: Mismatch between the legal business name on the IRS CP-575, the NPI registry, and the ND MMIS application.

11. Key Contacts and Resources

Providers should rely on the official North Dakota Department of Health and Human Services portals and federal CMS resources for the most current regulations, fee schedules, and application materials.

The ND MMIS EDI Help Desk and Provider Enrollment units are the primary contacts for billing, portal access, and enrollment troubleshooting.

• ND HHS Health Facilities Unit: State licensing authority and survey agency. URL: https://www.hhs.nd.gov/health/regulation-licensure-and-certification/health-facilities-unit/home-health-agencies
• ND MMIS Provider Enrollment Portal: For Medicaid applications and revalidation. URL: https://mmis.nd.gov/portals/wps/portal/ProviderEnrollment
• ND HHS Medicaid Provider Information: General Medicaid updates and fee schedules. URL: https://www.hhs.nd.gov/healthcare/medicaid/provider
• ND Medicaid Provider Enrollment Help: Email: dhsmed@nd.gov | Phone: (701) 328-7068 or (800) 755-2604.
• ND MMIS EDI Help Desk: For Trading Partner Agreement and electronic billing support. Phone: (844) 848-0844.
• North Dakota Secretary of State: For initial business registration. URL: https://sos.nd.gov

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