North Dakota Medicaid uses SFN 511 to request service authorization for surgical and medical procedures, devices, and provider-administered drugs. A clinic or surgeon's office meets it before a procedure that needs approval or when giving a drug that requires it. The Medical Services Division can assign two numbers, one clinical and one for the facility, and incomplete requests are returned.
The requesting provider's office completes recipient details, up to 10 ICD-10-CM codes, contact information and the procedure/device or provider-administered drug section, naming the billing provider and billing facility with NPIs. Reviewers complete the Remarks section.
Download the current version from the source each time; forms change without notice.
Medical Procedure/Device/Drug 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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When a procedure involves both a professional and a facility claim, the Medical Services Division assigns a clinical SA number for the billing provider and a facility SA number for the hospital or ambulatory surgery center. That is why the form asks for both billing provider and billing facility NPIs.
The form warns that CPT and HCPCS codes must be requested exactly as they will appear on the claim, with all applicable modifiers, and that failing to do so will result in denial of the claim. Incomplete requests are returned without a decision.