North Dakota Medicaid uses SFN 481 when a provider asks to exceed service limits for chiropractic care, physical, occupational or speech therapy, medical nutrition therapy, community health worker or paramedicine services, behavioral health rehabilitative services or targeted case management. Providers meet it when a member reaches a program limit but needs more care. The Medical Services Division approves or denies visits or units for a date range.
The billing or servicing provider completes provider, recipient and request details, explains medical necessity, signs, and checks the certification that the request is accurate and that the current coverage policy was reviewed. State staff complete the State Use Only section.
Download the current version from the source each time; forms change without notice.
Service Limits Service Authorization Request
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The area-of-request boxes are chiropractic services, community health worker, community paramedicine, occupational therapy, speech therapy and physical therapy units or evaluations, medical nutrition therapy, behavioral health rehabilitative services, and targeted case management. Check only one area per form.
Yes, but the form requires a good cause explanation before retroactive services will be considered. Include it in the designated field along with clinical documentation, the visits or units requested and the start and end dates.