reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:35 - Claims › Section 67:16:35:13 - Denied claims

Current through Register Vol. 51, page 10, July 15, 2024
The department may deny a claim for any of the following
	 reasons:
(1) The service claimed was
  not medically necessary;
(2) The
  claim is a duplicate of a prior paid claim;
(3) Third-party liability exists;
(4) The claim contains data that is logically
  inconsistent;
(5) The time limit
  for the submission of a claim has expired;
(6) The provider or recipient of service was
  not eligible when the service was provided;
(7) The drug is considered less than
  effective;
(8) The service is
  considered experimental;
(9) The
  claim contains erroneous, incomplete, or missing information;
(10) The claim is false or incorrect or
  violates provisions of this article; or
(11) The service is incidental to or an
  integral part of an allowable service.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Payments and obligations to be authorized by law -- Liability to
		state for unauthorized payments, SDCL
		4-8-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:35 - Claims › Section 67:16:35:14 - Remittance advice

Current through Register Vol. 51, page 10, July 15, 2024
The provider must reconcile the remittance advice with the patient's
	 records. The department shall send a warrant with the remittance advice when
	 the amount of a check is indicated on the remittance advice. The provider must
	 retain the remittance advice according to §
									67:16:34:05. Claims to be
	 resubmitted for payment must meet the requirements of §
									67:16:35:15.
When the department denies or pends a claim, the remittance advice
	 shall contain the specific reason the claim was denied or
	 pended.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Pended claims, §
											67:16:35:12.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:35 - Claims › Section 67:16:35:15 - Claim submission and resubmission limits

Current through Register Vol. 51, page 10, July 15, 2024
A participating provider may not submit a claim for a provider who has
	 been excluded or terminated from the medical assistance program or who
	 otherwise does not meet provider requirements in this article.
Claims for medically necessary covered services provided prior to a
	 provider's exclusion or termination may be submitted to the department after
	 the exclusion or termination.
A provider may not resubmit a claim to the department if the claim has
	 been pended, has already been paid, has been denied because it is not a covered
	 service or is not a medically necessary covered service, or is in violation of
	 this article. The resubmission of such a claim is considered an abuse of the
	 program and may be cause for terminating the provider agreement.
A previously denied claim may be resubmitted when there is new or
	 additional information which will substantiate the claim or when the previously
	 submitted incorrect data is resubmitted correctly.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Duration of agreement, §
											67:16:33:04.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:35 - Claims › Section 67:16:35:16 - Application of chapter

Current through Register Vol. 51, page 10, July 15, 2024
The rules in this chapter apply to all enrolled providers and
	 recipients.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:36 - Hospice services › Section 67:16:36:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Assisted living center," a facility as
  defined in SDCL subdivision 34-12-1.1(2);
(2) "Continuous home care day," a category of
  care as defined in 42 C.F.R.
  §
										418.302 (as amended to January 1,
  2010);
(3) "Community support
  provider," a nonprofit facility as defined in SDCL subdivision
  27B-1-17(4);
(4) "General inpatient
  care day," a category of care as defined in
  42 C.F.R. §
										418.302 (as amended to January 1,
  2010).
(5) "Hospice facility," an
  agency or organization engaged in providing care to terminally ill
  individuals;
(6) "Inpatient respite
  care day," a category of care as defined in
  42 C.F.R. §
										418.302 (as amended to January 1,
  2010;
(7) "Inpatient hospice," a
  facility as defined in SDCL subdivision 34-12-1.1(10);
(8) "ICF/IID," a facility as defined in
  §
									67:54:03:01;
(9) "Nursing facility," a facility as defined
  in SDCL subdivision 34-12-1.1(7);
(10) "Residential hospice," a facility as
  defined in SDCL subdivision 34-12-1.1(11);
(11) "Routine home care day," a category of
  care as defined in 42 C.F.R.
  §
										418.302 (as amended to January 1,
  2010;
(12) "Swing bed," a licensed
  hospital bed approved by the Department of Health to provide short-term nursing
  facility care pending the availability of a nursing facility bed; and
(13) "Terminally ill," a medical prognosis
  that an individual's life expectancy is six months or less if the illness runs
  its normal course.
General Authority:
SDCL
		28-6-1(1).
Law Implemented:
SDCL
		28-6-1(1).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:36 - Hospice services › Section 67:16:36:02 - Eligibility requirements - Individual

Current through Register Vol. 51, page 10, July 15, 2024
An individual is eligible for hospice services if the following
	 conditions are met:
(1) The individual
  has a written statement from a physician or other licensed practitioner that
  specifies that the individual is terminally ill; and
(2) The individual is eligible for medical
  assistance under this article.
General Authority:
SDCL 28-6-1(1).
Law Implemented:
SDCL
		28-6-1(1).
Certification of terminal illness,
		42 C.F.R. §
												418.22, as amended to July 1,
		2017.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:36 - Hospice services › Section 67:16:36:04 - Covered services - Limits

Current through Register Vol. 51, page 10, July 15, 2024
Hospice services are limited to the following:
(1) Routine home care provided in a
  recipient's place of residence, skilled nursing facility, ICF-IID, swing bed,
  assisted living center, residential hospice, community support provider, or
  inpatient hospice;
(2) General
  inpatient care provided in a skilled nursing facility, ICF-IID, swing bed,
  inpatient hospice, or hospital. The facility must provide 24-hour nursing
  services with a registered nurse providing direct patient care included in each
  shift;
(3) Continuous home care
  provided in a recipient's place of residence, long-term care facility,
  residential hospice, community support provider, or inpatient hospice;
  and
(4) For recipients residing in
  their own homes, assisted living centers, community support providers, or
  residential hospices, inpatient respite care may be provided at a nursing
  facility, inpatient hospice, or hospital.
A recipient receiving hospice services in a skilled nursing facility,
	 ICF-IID, swing bed, assisted living center, community support provider, or
	 inpatient hospice must meet the level of care requirements of chapter
	 67:45:01.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:36 - Hospice services › Section 67:16:36:05 - Reimbursement for room and board

Current through Register Vol. 51, page 10, July 15, 2024
A recipient's room and board is covered through the hospice benefit
	 under the following circumstances:
(1)
  If a recipient is receiving routine home care in an inpatient hospice;
  or
(2) If a recipient is receiving
  routine home care or continuous home care in a skilled nursing facility,
  ICF-IID, or swing bed.
For a recipient receiving routine home care or continuous home care in
	 a skilled nursing facility, ICF-IID, or swing bed, the hospice provider is paid
	 95% of the per diem rate that would have been paid to the facility. The
	 facility is paid by the hospice provider pursuant to their written agreement as
	 required by 42 C.F.R. §
											418.112, as amended to January 1,
	 2010.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:36 - Hospice services › Section 67:16:36:06 - Notice requirements

Current through Register Vol. 51, page 10, July 15, 2024
The hospice provider shall submit notice on a form designated by the
	 department if a recipient elects or revokes the hospice benefit, dies, or
	 discharges from the hospice provider's care. Notice must be sent to the
	 department within five working days of the event.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:36 - Hospice services › Section 67:16:36:07 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for services provided under the provisions of this chapter must
	 follow the requirements established in §
									67:16:03:14. The hospice facility
	 shall submit a separate claim for each individual receiving hospice services
	 and shall submit a new claim each time the individual's category of care
	 changes during a calendar month.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:36 - Hospice services › Section 67:16:36:08 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review of hospice services may be conducted on three
	 levels:
(1) Claims review;
(2) Auditing; and
(3) Post-payment review.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:36 - Hospice services › Section 67:16:36:09 - Application of other chapters

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the rules contained in this chapter, providers and
	 recipients must meet the requirements of article 67:45 and chapters 67:16:01,
	 67:16:26, 67:16:33, 67:16:34, and 67:16:35.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Care plan," a written plan for a
  particular individual which outlines medically necessary health services and
  the duration of those services, including an individual education program
  (IEP), individual family service plan (IFSP) or other qualifying plan prepared
  by school officials. A qualifying care plan must contain the individual's
  diagnosis, the scope and duration of the service to be provided, and evidence
  establishing medical necessity of the service according to
  67:16:01:06.02;
(2) "School
  district," an education unit defined by SDCL
  13-5-1; an agency that operates a
  special education program for children with disabilities, birth through 21
  years of age, and meets the requirements of article 24:05; or a cooperative
  special education unit created by two or more school districts under SDCL
  13-5-32.1; and
(3) "Unit," a 15-minute measurement of time
  or fraction thereof.
General Authority:
SDCL
		28-6-1(1).
Law Implemented:
SDCL
		28-6-1(1).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:02 - School district may be medical assistance provider

Current through Register Vol. 51, page 10, July 15, 2024
A school district may be a medical assistance provider if the following
	 conditions are met:
(1) The school
  district provides any of the services covered by this chapter;
(2) The covered services are provided by an
  employee of the school district or by an individual who is under contract with
  the school district and who meets the applicable licensing or certification
  requirements of §
									67:16:37:05; and
(3) The school district has a signed provider
  agreement with the department.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:03 - Care plan required

Current through Register Vol. 51, page 10, July 15, 2024
The school district must have a care plan for each individual
	 receiving medical services under this chapter. Professionals involved in the
	 child's care must prepare the care plan.
The care plan may not be effective for more than one school year and it
	 must be amended as warranted by changes in the individual's medical
	 condition.
There must be a physician or other licensed practitioners written
	 orders for medical services required under the care plan.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(4).
Individual education program (IEP), ch 24:05:27; Content of the
		individual family service plan (IFSP),
		34 C.F.R. §
												303.344, as amended to July 1,
		2017.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:04 - Service restrictions

Current through Register Vol. 51, page 10, July 15, 2024
A service provided under this chapter must meet the following
	 conditions:
(1) The service must be
  medically necessary. Evidence establishing the medical necessity must be
  maintained in the individual's record;
(2) The service must be outlined in the
  individual's care plan;
(3) The
  service must be within the professional's scope of practice;
(4) The service must be a direct,
  face-to-face, contact-care service with the individual;
(5) The service may only be provided to
  individuals under age 21; and
(6)
  The service must be provided by the school district in which the individual
  resides.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Covered services must be medically necessary, §
											67:16:01:06.02.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:04.01 - Covered services - Limits

Current through Register Vol. 51, page 10, July 15, 2024
Services covered under this chapter are limited to the
	 following:
(1) Psychological services
  under §
									67:16:37:06;
(2) Physical therapy services;
(3) Occupational therapy services;
(4) Speech therapy services;
(5) Audiology services; and
(6) Nursing services under §
									67:16:37:11.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Covered services must be medically necessary, §
											67:16:01:06.02.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:05 - Required licensure or certification requirements for service provider

Current through Register Vol. 51, page 10, July 15, 2024
An individual providing services under this chapter must meet the
	 following licensure or certification requirements, as applicable:
(1) Psychology services listed in §
									67:16:37:06 must be provided
  either by a provider listed in §
									67:16:41:03 or by a psychological
  evaluator that meets the requirements of §
									24:05:23:02;
(2) Physical therapy services must be
  provided either by a physical therapist licensed under SDCL 36-10 or by a
  graduate physical therapy assistant certified under SDCL 36-10;
(3) Occupational therapy services must be
  provided by an occupational therapist licensed under SDCL 36-31, an
  occupational therapy assistant licensed under SDCL 36-31, or an occupational
  therapy aide who assists in the practice of occupational therapy under SDCL
  36-31 and article 20:64;
(4) Speech
  therapy services must be provided by a speech-language pathologist licensed
  under SDCL 36-37, or a speech-language pathology assistant licensed under SDCL
  36-37;
(5) Audiology services must
  be provided by an audiologist licensed under SDCL 36-24; and
(6) Nursing services listed in §
									67:16:37:11 must be provided by a
  professional nurse licensed under SDCL 36-9.
General Authority:
SDCL
		28-6-1(1)(2).
Law Implemented:
SDCL
		28-6-1(1)(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:06 - Covered psychological services

Current through Register Vol. 51, page 10, July 15, 2024
Psychological services are limited to the following:
(1) Integrated screening, assessment, and
  evaluation;
(2) Individual
  therapy:
(3) Group
  therapy;
(4) Parent or guardian
  group therapy; and
(5) Family
  education, support, and therapy.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Rate of payment, §
											67:16:37:12; Billing requirements,
		§
											67:16:37:14.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:10.01 - Requirements for supervising speech-language pathologist

Current through Register Vol. 51, page 10, July 15, 2024
If speech therapy services are provided by a speech-language pathology
	 assistant, the supervising speech-language pathologist must meet the
	 requirements for a supervising speech-language pathologist contained in chapter
	 20:79:04:
(1) The speech-language
  pathologist must either be employed by or have a formal contractual agreement
  with the school district to supervise the speech therapy services provided to
  recipients by a speech-language pathology assistant. Supervisory requirements
  must be documented in the contractual agreement or included in the employee's
  job description.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Required licensure or certification requirements for service
		provider, §
											67:16:37:05; Records, ch 67:16:34;
		Speech-language pathology assistants, ch
		20:79:04.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:11 - Covered nursing services

Current through Register Vol. 51, page 10, July 15, 2024
Nursing services are limited to the following services provided to
	 treat a chronic medical illness:
(1)
  Nursing evaluation or assessment, which includes observation of recipients with
  chronic medical illnesses in order to assure that medical needs are being
  appropriately identified, addressed, and monitored;
(2) Nursing treatment, which includes
  administration of medication; management and care of specialized feeding
  program, management and care of specialized medical equipment such as colostomy
  bags, nasalgastric tubes, tracheostomy tubes; and
(3) Extended nursing care for
  technology-dependent child who relies on life-sustaining medical technology to
  compensate for the loss of a vital body function and requires ongoing complex
  hospital-level nursing care to avert death or further disability.
Extended nursing care is limited to services provided in the school
	 during normal school hours. Routine nursing services which are provided to all
	 students by a school nurse, such as treatment of minor abrasions, cuts, and
	 contusions; recording of temperature or blood pressure; and evaluation or
	 assessment of acute illness, are not covered services under this
	 chapter.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Rate of payment, §
											67:16:37:12; Billing requirements,
		§
											67:16:37:14.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:12 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment for services under this chapter is limited to the lesser of the
	 federal share of the provider's usual and customary charge or the federal share
	 of the rate negotiated between the department of education and the school
	 district.
The federal share is the percentage calculated according to
	 42 U.S.C. §
										1301 (October 1, 1991).
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:13 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for school district services may be conducted on the
	 following levels:
(1) Computerized
  claims processing;
(2) Postpayment
  review; and
(3) Peer
  review.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:14 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
A school district submitting a claim for covered services under this
	 chapter must submit the claim at its usual and customary charge.
The school district must submit the claim when the service is listed in
	 the child's care plan and is covered under this chapter. Services provided to
	 an individual who has been admitted to a hospital as an inpatient, or who is
	 residing in a residential treatment center, a nursing facility, or an
	 intermediate care facility for individuals with intellectual disabilities are
	 exempt from the provisions of this rule. Claims for these services must be
	 submitted according to the applicable chapters of article 67:16.
A provider, other than those listed above, may not submit claims for
	 services which the provider knows or should have known are services listed in
	 the child's care plan.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:15 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for services provided under this chapter must be submitted on
	 a form which contains the following information:
(1) The recipient's full name;
(2) The recipient's medical assistance
  identification number from the recipient's medical assistance identification
  card;
(3) The third-party liability
  information required under chapter 67:16:26;
(4) The date of service;
(5) The place of service;
(6) The provider's usual and customary
  charge. The provider may not subtract other third-party or cost-sharing
  payments from this charge;
(7) The
  procedure codes designated for services covered under this chapter, listed on
  the department's billing guidance website;
(8) The units of service furnished, if more
  than one;
(9) The billing
  provider's name and National Provider Identification (NPI) number;
  and
(10) The National Provider
  Identification (NPI) number of the servicing provider who provided or
  supervised the care or service.
A separate claim form must be used for each recipient.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Note:
The CMS 1500 form substantially meets the
		requirements of this rule and its content and appearance are acceptable to the
		department. These forms are available for direct purchase through the
		Superintendent of Documents, U.S. Government Printing Office, Washington, D.C.
		20402. (202) 783-3238 - pricing desk.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:37 - School districts › Section 67:16:37:16 - Application of other chapters

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the rules contained in this chapter, providers and
	 recipients must meet the requirements of chapters 67:16:01, 67:16:26, 67:16:33,
	 67:16:34, and 67:16:35.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:38 - Case management - Severely and persistently mentally ill › Section 67:16:38:10

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:38 - Case management - Severely and persistently mentally ill › Section 67:16:38:11

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:38 - Case management - Severely and persistently mentally ill › Section 67:16:38:12

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:38 - Case management - Severely and persistently mentally ill › Section 67:16:38:13

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:38 - Case management - Severely and persistently mentally ill › Section 67:16:38:14

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:38 - Case management - Severely and persistently mentally ill › Section 67:16:38:15

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:38 - Case management - Severely and persistently mentally ill › Section 67:16:38:16

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:38 - Case management - Severely and persistently mentally ill › Section 67:16:38:17

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Claims, ch 67:16:35.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:38 - Case management - Severely and persistently mentally ill › Section 67:16:38:18

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Designated covering provider," another
  physician at the PCP's clinic who has an arrangement with a PCP to act as the
  recipient's PCP when the recipient's PCP is unable to see the
  recipient;
(2) "Primary care
  provider program," a program which requires the management and treatment of a
  recipient's medical care by a single primary care provider, including necessary
  referrals by the primary care provider for specialty care or
  services;
(3) "Primary care
  provider" or "PCP," the physician or facility chosen by the recipient or
  assigned by the department under the provisions of §§
									67:16:39:05 and
  67:16:39:06 to provide primary
  care provider program services; and
(4) "Primary health care services," the
  prescribing of or directing the use for any person any drug, medicine,
  apparatus, or other agency for the cure, relief, or palliation of any ailment
  or disease of the mind or body or the cure or relief of any wound, fracture,
  bodily injury, or deformity.
General Authority:
SDCL
		28-6-1(1)(4).
Law Implemented:
SDCL
		28-6-1(1)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:02 - Individuals required to participate

Current through Register Vol. 51, page 10, July 15, 2024
An individual is required to participate in the primary care provider
	 program if the individual is covered under subdivisions 67:46:01:02(1), (2) if
	 the individual is at least 19 years old, (7), (9), (11) to (17), inclusive, or
	 (22) to (24), inclusive. If the individual qualifies under one of the
	 subdivisions but is a recipient of Medicare, long-term care services, home and
	 community-based services, community center services provided at an adjustment
	 training center, foster care services, or subsidized adoption services, the
	 individual is exempt from participating in the primary care provider
	 program.
General Authority:
SDCL
		28-6-1(1)(4).
Law Implemented:
SDCL
		28-6-1(1)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:03 - Effective dates of program

Current through Register Vol. 51, page 10, July 15, 2024
The provisions of this chapter become effective the first full calendar
	 month after the recipient chooses a PCP or the department assigns a PCP to the
	 recipient.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Choice of primary care provider, §
											67:16:39:06.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:04 - Recipient responsible for payment of noncovered services

Current through Register Vol. 51, page 10, July 15, 2024
Medical expenses incurred outside the rules of this chapter are
	 considered noncovered services and payment for those services is the
	 responsibility of the recipient.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Use of medical assistance identification card required, §
											67:16:39:09.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:05 - Provider requirements

Current through Register Vol. 51, page 10, July 15, 2024
A primary care provider must:
(1) Have an approved and signed medical
  assistance provider agreement with the department under chapter
  67:16:33;
(2) Have an approved and
  signed primary care provider addendum to the provider agreement with the
  department under this chapter; and
(3) Be licensed as a physician, osteopath,
  physician assistant, certified nurse practitioner, or certified nurse midwife
  by the state in which the practitioner is located or be a rural health clinic,
  a federally qualified health care center, a tribal provider with a contract
  under public law 93-638, or an Indian Health Service clinic and have agreed to
  provide primary health care services under this chapter.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
Licensing requirements for physicians and osteopaths, SDCL ch 36-4;
		Licensing requirements for physician assistants, SDCL ch 36-4A; Licensing
		requirements for certified nurse practitioners and certified nurse midwifes,
		SDCL ch 36-9A; Certification and approval of rural health clinics and federally
		qualified health care centers, 42 C.F.R. §
		491.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:06 - Choice of primary care provider

Current through Register Vol. 51, page 10, July 15, 2024
An individual required to participate in the primary care provider
	 program must select a primary care provider from a list of participating PCPs.
	 The department shall supply a list of PCPs to the individual.
An individual's choice of a primary care provider must be received in
	 writing by or conveyed verbally to the department within 10 days after the
	 department supplies the list of PCPs to the individual. If an individual fails
	 to make a selection, the department shall assign a PCP to the
	 individual.
The department shall send a written notice to the individual and the
	 PCP confirming the choice or assignment of a PCP to the individual and the
	 effective date.
General Authority:
SDCL
		28-6-1(1)(4).
Law Implemented:
SDCL
		28-6-1(1)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:07 - Change in primary care provider

Current through Register Vol. 51, page 10, July 15, 2024
The primary care provider selection remains in effect until:
(1) The recipient submits a written or verbal
  request for a provider change to the department during the recipient's annual
  redetermination of eligibility; or
(2) The recipient or primary care provider
  submits a written or verbal request to the department. The department shall
  approve or disapprove the change request and shall notify the primary care
  provider and the recipient of the decision.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:08 - Primary care provider to provide service or refer recipient for service

Current through Register Vol. 51, page 10, July 15, 2024
Medically necessary covered services provided under the primary care
	 provider program must be provided by the recipient's PCP or by another enrolled
	 medical assistance provider to whom the PCP referred the recipient.
Medical services provided by someone other than the recipient's PCP or
	 services provided without referral and authorization by the PCP are noncovered
	 services and may be cause for denial by the department.
General Authority:
SDCL
		28-6-1(1)(2)(4).
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
Recipient responsible for payment of noncovered services, §
											67:16:39:04.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:09 - Use of medical assistance identification card required

Current through Register Vol. 51, page 10, July 15, 2024
For a service to be covered, a recipient must present the recipient's
	 medical assistance identification card to a provider before obtaining the
	 service. Failure to present the card is cause for payment denial. Payment for
	 such denied service becomes the responsibility of the
	 recipient.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Recipient responsible for payment of noncovered services, §
											67:16:39:04; Primary care case
		management services, §
											67:16:39:10.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:10 - Primary care provider program services

Current through Register Vol. 51, page 10, July 15, 2024
Primary care provider program services include the following medically
	 necessary covered services:
(1)
  Physician services listed in chapter 67:16:02;
(2) Inpatient/outpatient hospital services
  listed in chapter 67:16:03;
(3)
  Home health services listed in chapter 67:16:05;
(4) Screening services listed in chapter
  67:16:11;
(5) Clinic services
  listed in chapter 67:16:13;
(6)
  Ambulatory surgical center services listed in chapter 67:16:28;
(7) Medical equipment services listed in
  chapter 67:16:29;
(8) Organ
  transplants listed in chapter 67:16:31;
(9) School district services listed in
  chapter 67:16:37;
(10) Mental
  health services listed in chapter 67:16:41;
(11) Federally qualified health center and
  rural health center services listed in chapter 67:16:44; and
(12) Diabetes self-management training listed
  in chapter 67:16:46.
General Authority:
SDCL
		28-6-1(1)(4).
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:11 - Exempt services

Current through Register Vol. 51, page 10, July 15, 2024
The following medically necessary covered services are exempt from the
	 provisions of this chapter:
(1) Family
  planning services;
(2) Emergency
  services as defined in chapter 67:16:01;
(3) Dental services listed in chapter
  67:16:06;
(4) Podiatric services
  listed in chapter 67:16:07;
(5)
  Optometric and optical services listed in chapter 67:16:08;
(6) Chiropractic services listed in chapter
  67:16:09;
(7) Immunization,
  home-based therapy, dental, orthodontic, and chemical dependency treatment
  services listed in chapter 67:16:11;
(8) Mental health services for individuals
  who are diagnosed with a serious emotional disturbance as defined in §
									67:62:11:01 or serious mental
  illness as defined in §
									67:62:12:01;
(9) Prescription drug services listed in
  chapter 67:16:14;
(10) Personal
  care services listed in chapter 67:16:24;
(11) Transportation services listed in
  chapter 67:16:25; and
(12) Four
  urgent care visits per year, per recipient.
General Authority:
SDCL
		28-6-1(1)(2)(4).
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:13 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
Claims submitted under this chapter must meet the following
	 requirements:
(1) Physician services
  must follow the billing requirements contained in chapter 67:16:02;
(2) Inpatient/outpatient hospital services
  must follow the billing requirements contained in chapter 67:16:03;
(3) Home health services must follow the
  billing requirements contained in chapter 67:16:05;
(4) Screening services must follow the
  billing requirements contained in chapter 67:16:11;
(5) Clinic services must follow the billing
  requirements contained in chapter 67:16:13;
(6) Ambulatory surgical center services must
  follow the billing requirements contained in chapter 67:16:28;
(7) Medical equipment services must follow
  the billing requirements contained in chapter 67:16:29;
(8) Organ transplant services must follow the
  billing requirements contained in chapter 67:16:31;
(9) School district services must follow the
  billing requirements contained in chapter 67:16:37;
(10) Mental health services provided by
  independent practitioners must follow the billing requirements contained in
  chapter 67:16:41;
(11) Federally
  qualified health center and rural health clinic services must follow the
  billing requirements contained in chapter 67:16:44;
(12) Diabetes self-management training must
  follow the billing requirements contained in chapter 67:16:46; and
(13) Chemical dependent and substance abuse
  treatment services must follow the billing requirements contained in chapter
  67:16:48.
A provider may not, on behalf of a recipient, submit a claim for
	 services provided under this chapter unless the provider is the recipient's
	 primary care provider or unless the covered service was provided as a result of
	 a referral and authorization by the recipient's primary care provider.
If a recipient's primary care provider is submitting a claim for
	 covered services, the claim must contain the primary care provider's National
	 Provider Identifier number. If a provider is submitting a claim for covered
	 services provided as a result of a referral and authorization by the
	 recipient's primary care provider, the claim must contain the provider's
	 National Provider Identifier number, as well as the National Provider
	 Identifier number of the recipient's primary care provider.
A claim submitted without the required National Provider Identifier
	 (NPI) number is cause for denial by the department.
General Authority:
SDCL
		28-6-1(1)(2)(4).
Law Implemented:
SDCL
		28-6-1.
Records, ch 67:16:34.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:15 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
Claims submitted under this chapter must meet the following
	 requirements:
(1) Physician services
  must follow the claim requirements contained in chapter 67:16:02;
(2) Inpatient/outpatient hospital services
  must follow the claim requirements contained in chapter 67:16:03;
(3) Home health services must follow the
  claim requirements contained in chapter 67:16:05;
(4) Screening services must follow the claim
  requirements contained in chapter 67:16:11;
(5) Clinic services must follow the claim
  requirements contained in chapter 67:16:13;
(6) Ambulatory surgical center services must
  follow the claim requirements contained in chapter 67:16:28;
(7) Medical equipment services must follow
  the claim requirements contained in chapter 67:16:29;
(8) Organ transplant services must follow the
  claim requirements contained in chapter 67:16:31;
(9) School district services must follow the
  claim requirements contained in chapter 67:16:37;
(10) Mental health services provided by
  independent practitioners must follow the claim requirements contained in
  chapter 67:16:41;
(11) Federally
  qualified health center and rural health clinic services must follow the claim
  requirements contained in chapter 67:16:44;
(12) Diabetes self-management training must
  follow the claim requirements contained in chapter 67:16:46; and
(13) Chemical dependency and substance abuse
  treatment services must follow the claim requirements contained in chapter
  67:16:48.
If a provider is submitting a claim for covered services provided as a
	 result of a referral and authorization by the recipient's primary care
	 provider, the claim must contain the provider's National Provider Identifier
	 number as well as the National Provider Identifier number of the recipient's
	 primary care provider.
General Authority:
SDCL
		28-6-1(1)(2)(4).
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:39 - Care management - Primary care provider › Section 67:16:39:17 - Cost share exemption

Current through Register Vol. 51, page 10, July 15, 2024
Services provided by the recipient's PCP or a designated covering
	 provider at the PCP's clinic if the PCP is unavailable are exempt from cost
	 sharing.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Activities of daily living," an
  individual's physical functions including the ability to bathe, dress, eat,
  toilet, and move;
(2) "Care
  conference," a meeting of medical professionals specifically involved in an
  individual's care used to determine the individual's plan of care and the
  disposition of medical treatment;
(3) "Care management," the monitoring of
  certain inpatient admissions to assure the medical necessity of the admission,
  monitor the need for a continued stay in the unit, and assist in facilitating
  the individual's discharge from the unit;
(4) "Care management consultant," a physician
  or psychiatrist who has a contract with the Department of Social Services to
  review case files;
(5) "Care
  manager," a medical professional or medical review organization employed by or
  under contract with the Department of Social Services who is responsible for
  care management;
(6) "Functional,"
  the ability to perform the activities of daily living either independently or
  with assistance from another individual;
(7) "Hospital representative," the person
  designated by a participating hospital as the hospital's primary contact person
  for the care manager;
(8)
  "Long-term care hospital unit," a hospital within a licensed acute care
  hospital that provides long-term inpatient care to recipients who need acute
  care and are chronically ill, ventilator dependent, or in need of specialized
  monitoring; and
(9) "Working day,"
  the days of the week consisting of Monday through Friday except those days
  considered holidays as specified in SDCL
  1-5-1.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:02 - Certain hospitals required to participate in care management

Current through Register Vol. 51, page 10, July 15, 2024
An acute care hospital which is a participating provider in the medical
	 assistance program and has a unit which is exempt from the DRG basis of
	 reimbursement provisions must participate in care management. Units exempt from
	 the DRG provisions include the following:
(1) A rehabilitation unit;
(2) A psychiatric unit;
(3) A neonatal unit; and
(4) A long-term care hospital unit.
An out-of-state rehabilitation hospital and an out-of-state acute care
	 hospital is subject to the conditions of this chapter if it admits an
	 individual from South Dakota to any of the units listed in this section and if
	 that individual is required to participate in care management under §
										67:16:40:03.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Certain in-state hospitals, hospital units, and procedures exempt
		from DRG basis of reimbursement, §
											67:16:03:06.02.