reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:05.01 - Physical therapy services covered

Current through Register Vol. 51, page 10, July 15, 2024
Physical therapy services which are ordered by a physician or other
	 licensed practitioner through a written prescription and provided by a physical
	 therapist licensed under SDCL 36-10 or by a physical therapist assistant
	 certified under SDCL 36-10 are covered services under this article.
Services provided by a physical therapist assistant shall be billed by
	 the supervising physical therapist.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
School districts, ch 67:16:37.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:05.08

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 67:16:02 - Physician and other health services › Section 67:16:02:05.09

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 67:16:02 - Physician and other health services › Section 67:16:02:05.10

Current through Register Vol. 51, page 10, July 15, 2024
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 67:16:02 - Physician and other health services › Section 67:16:02:05.13

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 67:16:02 - Physician and other health services › Section 67:16:02:05.14

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 67:16:02 - Physician and other health services › Section 67:16:02:05.15 - Occupational therapy

Current through Register Vol. 51, page 10, July 15, 2024
Occupational therapy services are covered services if ordered by a
	 physician or other licensed practitioner through a written prescription and
	 provided by a occupational therapist licensed under SDCL 36-31, occupational
	 therapy assistant licensed under SDCL 36-31.
Services provided by an occupational therapy assistant shall be billed
	 by the supervising occupational therapist.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
School districts, ch 67:16:37.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:06 - Health services not covered

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the services not specifically listed in §
									67:16:02:05, the following health
	 services and items are not covered under the medical assistance program:
(1) Medical equipment for a resident in a
  nursing facility, an intermediate care facility for individuals with
  intellectual disabilities, or an institution for individuals with a mental
  disease;
(2) Self-help devices,
  exercise equipment, protective outerwear, and personal comfort or environmental
  control equipment, including air conditioners, humidifiers, dehumidifiers,
  heaters, and furnaces;
(3) Any
  weight loss program or activity;
(4) Agents to promote fertility;
  and
(5) Procedures to reverse a
  previous sterilization.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Medical equipment, chapter 67:16:29; Services not covered, §
											67:16:01:08.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:07 - Utilization review for physician, laboratory, and X-ray services

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for physician, laboratory, and X-ray services may be
	 provided on three levels:
(1)
  Computerized claims processing;
(2)
  Postpayment reviews; 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 67:16:02 - Physician and other health services › Section 67:16:02:09 - Sterilization

Current through Register Vol. 51, page 10, July 15, 2024
Payment for sterilization is limited to those procedures performed on a
	 recipient who meets the following criteria:
(1) Is at least 21 years old;
(2) Is a legally competent
  individual;
(3) Has signed an
  informed consent form after the recipient's 21st birthday; and
(4) At least 30 days but not more than 180
  days have passed between the date the informed consent form was signed and the
  date of the sterilization.
In the case of a premature delivery, subdivision (4) of this section
	 may be waived if the informed consent form was signed at least 30 days before
	 the expected delivery date and if at least 72 hours have passed between the
	 time the informed consent form was signed and the time of the delivery.
In the case of emergency abdominal surgery, subdivision (4) of this
	 section may be waived if the informed consent form was signed at least 72 hours
	 before the emergency surgery was performed.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Sterilization of a mentally competent individual aged 21 or older,
		42 C.F.R. §
												441.253.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:10 - Refractions and eyeglasses

Current through Register Vol. 51, page 10, July 15, 2024
Payable physician services relating to refractions and the provision of
	 eyeglasses are subject to the limits established in chapter
	 67:16:08.
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 67:16:02 - Physician and other health services › Section 67:16:02:11

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Medical equipment payable, §
											67:16:02:12; Cost-sharing
		participants, §
											67:16:01:22.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:13 - Audiological and speech pathology services

Current through Register Vol. 51, page 10, July 15, 2024
Payment may be made for audiological testing and speech-language
	 pathology services if provided by a physician, a clinical audiologist licensed
	 under 36-24, a speech-language pathologist licensed under SDCL 36-37, or a
	 speech-language pathology assistant licensed under SDCL 36-37.
Covered services are limited to those services provided by a physician
	 or by the clinical audiologist, speech-language pathologist, or speech-language
	 pathology assistant if the patient has a written referral from a physician or
	 other licensed practitioner and the services are necessary to diagnose or treat
	 a medical problem.
Services provided by a speech-language pathology assistant shall be
	 billed by the supervising speech-language pathologist.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
NOTE:
Information relating to certification as a
		clinical audiologist or speech pathologist may be obtained from the American
		Speech and Hearing Association, 10801 Rockville Pike, Rockville, Maryland
		20852.
School districts, ch 67:16:37.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:14 - Reimbursement for services provided by nurse midwife or nurse anesthetist

Current through Register Vol. 51, page 10, July 15, 2024
Services provided by a nurse midwife or a nurse anesthetist are
	 reimbursed at the rate for the same services provided by a
	 physician.
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 67:16:02 - Physician and other health services › Section 67:16:02:15 - Reimbursement for services provided by nurse practitioner, clinical nurse specialist, or physician assistant

Current through Register Vol. 51, page 10, July 15, 2024
Except for laboratory services, radiological services, immunizations,
	 and supplies, services provided by a nurse practitioner, a clinical nurse
	 specialist, or a physician assistant are reimbursed at 90 percent of the fee
	 established under this chapter.
Reimbursement for laboratory services, radiological services,
	 immunizations, and supplies provided by a nurse practitioner, a clinical nurse
	 specialist, or a physician assistant are reimbursed according to §
									67:16:02:03.
General Authority:
SDCL
		28-6-1.
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 67:16:02 - Physician and other health services › Section 67:16:02:16 - Billing requirements - Modifier codes - Provider identification numbers

Current through Register Vol. 51, page 10, July 15, 2024
A claim submitted under this chapter must be submitted at the
	 provider's usual and customary charge.
The laboratory that performed the laboratory test must submit the claim
	 for the test.
If relevant, the claim shall identify the modifying circumstance of a
	 service or procedure by the addition of the applicable modifier code to the
	 procedure code.
A claim submitted for multiple surgeries must contain the applicable
	 procedure code for the primary surgical procedure. All other procedures
	 performed during the same operating session must be billed using the applicable
	 procedure code and modifier 51. A bilateral procedure or a surgical procedure
	 which cannot stand alone but which is performed as a part of a primary surgical
	 procedure, such as procedure code 15261, is not considered a multiple surgical
	 procedure.
A claim submitted by a clinical nurse specialist, a nurse practitioner,
	 or a physician assistant must contain the nurse practitioner's, the clinical
	 nurse specialist's, or the physician assistant's provider identification number
	 and may not be submitted under the supervising physician's identification
	 number.
A claim submitted for immunizations must contain the applicable
	 procedure code for the administration of the vaccine and an additional
	 procedure code for the vaccine itself. If the vaccine is supplied by the state,
	 the billing code for the vaccine must contain the two-letter modifier of
	 SL.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Required modifier codes, §
											67:16:02:03.03.
Third-party liability, ch 67:16:26.
Claims, ch 67:16:35.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:16.01 - Billing requirements - Implantable contraceptive capsules and obstetrical services

Current through Register Vol. 51, page 10, July 15, 2024
When computing the rate of reimbursement, the department uses the fee
	 schedules established under the provisions of §
									67:16:02:01.01. A claim submitted
	 under this chapter for covered implantable contraceptive capsules and
	 obstetrical services must be submitted at the provider's usual and customary
	 charge and is limited to the nonlaboratory procedure codes listed in the
	 applicable fee schedule.
A claim submitted for insertion or reinsertion, implantable
	 contraceptive capsule may not include the cost of the kit. The kit must be
	 billed separately.
Providers must use the appropriate CPT code to indicate obstetric care,
	 antepartum care, delivery, and postpartum care. When applicable, providers must
	 bill using the global delivery codes defined on the department's billing
	 guidance website. A provider may not separate claims for antepartum care,
	 delivery services, or postpartum care when using a global delivery code.
A claim submitted for postpartum care is limited to hospital and office
	 visits in the 60 days following vaginal or cesarean section delivery.
The guidelines adopted in §
									67:16:01:25 apply unless otherwise
	 noted in this chapter.
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 67:16:02 - Physician and other health services › Section 67:16:02:17 - 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 or in an electronic format that 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)
  Third-party liability information required under chapter 67:16:26;
(4) Date of service;
(5) 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)
  Units of service furnished if more than one;
(8) The applicable procedure codes from
  either the
Health Care Common Procedure Coding System
(HCPCS) or
  the
Current Procedural Terminology
(CPT);
(9) The applicable diagnosis codes adopted in
  §
									67:16:01:26;
(10) The provider's name and National
  Provider Identification (NPI) number;
(11) If the provider is a group provider, the
  National Provider Identification number of the physician or applicable,
  enrolled provider who provided the care or service;
(12) Type of service; and
(13) The modifier code listed in §
									67:16:02:03.03, as applicable.
A separate claim must be submitted for each recipient.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(2)(4).
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.
Claims, ch 67:16:35.
Use of CPT, §
											67:16:01:25.
Use of HCPCS, §
											67:16:01:27.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:18

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 67:16:02 - Physician and other health services › Section 67:16:02:19 - 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, 67:16:35, and 67:16:39.
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 67:16:02 - Physician and other health services › Appendix D - List of Modifier Codes for Physician Services, transferred to Section 67:16:02:03.03, effective September 12, 2007

Current through Register Vol. 51, page 10, July 15, 2024
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Benefit period," a period of days for
  which an individual may receive benefits for inpatient hospital
  services;
(2) "Case mix index," the
  sum of the DRG weight factors for all Medicaid discharges for a hospital during
  a specific time span divided by the number of discharges;
(3) "Cost outlier," a hospital claim with 70
  percent of the billed charges exceeding the greater of 1.5 times the standard
  DRG payment amount or the outlier threshold available on the department's fee
  schedule website;
(4)
  "Diagnosis-related group," "DRG," a classification assigned to an inpatient
  hospital service claim based on the patient's age and sex, the principal and
  secondary diagnoses, the procedures performed, and the discharge
  status;
(5) "Emergency hospital
  care," the care necessary to prevent the death or serious impairment of the
  health of the recipient after the sudden onset of a medical condition that is
  manifested by symptoms of sufficient severity so as to be life-threatening or
  require immediate medical intervention;
(6) "Hospital services," items and services
  provided on the hospital's premises to a patient by a hospital under the
  direction of a physician or a dentist;
(7) "Inpatient," a patient who has been
  admitted to a hospital on the recommendation of a physician or a
  dentist;
(8) "Outpatient," a
  patient who receives professional services at a participating hospital, but is
  not provided with room, board, and services on a 24-hour basis;
(9) "Participating hospital," a hospital
  owned by the state in which it is located or licensed by the state licensing
  agency of the state in which it is located, certified by Medicare under Title
  XVIII of the Social Security Act, as amended to January 1, 2010, which agrees
  to participate under the medical assistance program; and
(10) "Target amount," a hospital's average
  Medicaid cost per discharge for routine services divided by its case mix
  index.
General Authority:
SDCL
		28-6-1(1)(2)(3).
Law Implemented:
SDCL
		28-6-1(1)(2)(3),
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:01.03 - Determination of emergency hospital care

Current through Register Vol. 51, page 10, July 15, 2024
The physician or other licensed practitioner on duty or on call at a
	 hospital must determine whether the individual requires emergency hospital
	 care. The need for emergency hospital care is established when the absence of
	 emergency care could be expected to result in one of the following:
(1) Death;
(2) Additional serious jeopardy to the
  individual's health;
(3) Serious
  impairment to the individual's bodily functions; or
(4) Serious dysfunction of any bodily organ
  or part.
Emergency hospital service does not include that care for which
	 treatment is available and routinely provided in a clinic or
	 office.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:02 - Inpatient hospital services covered

Current through Register Vol. 51, page 10, July 15, 2024
The following inpatient hospital services covered under the medical
	 assistance program are available to eligible individuals:
(1) Semiprivate room accommodations and
  board. Private rooms are covered when justified by a statement of medical
  necessity from the attending physician or other licensed
  practitioner;
(2) Regular nursing
  services routinely furnished by a hospital;
(3) Supplies, such as splints and casts, and
  use of appliances and equipment, such as wheelchairs, crutches, and
  prostheses;
(4) Whole blood or
  packed red cells;
(5) Diagnostic
  services;
(6) Therapeutic
  services;
(7) Operating and
  delivery rooms;
(8) Drugs and
  biologicals ordinarily furnished by the hospital;
(9) Medical social services;
(10) Services of hospital residents and
  interns who are in approved training programs;
(11) Dialysis treatments;
(12) Services of hospital-based physicians or
  other licensed practitioners;
(13)
  Sterilizations authorized under §
									67:16:02:09;
(14) Hysterectomies authorized under
  42 C.F.R. §§
										441.250 to
  441.259, inclusive (as amended to
  April 1, 2017); and
(15) Services
  listed on the department's prior authorization website if authorized under
  § 67:16:03:02.01.
General Authority:
SDCL
		28-6-1.
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 67:16:03 - Hospital services › Section 67:16:03:02.01 - Inpatient hospital services requiring prior authorization

Current through Register Vol. 51, page 10, July 15, 2024
The attending physician, other licensed practitioner, representative
	 of the physician or other licensed practitioner, or the hospital must obtain
	 prior authorization from the department or the department's authorized
	 representative before an inpatient hospital service listed on the department's
	 prior authorization website is provided.
The required service is exempt from the provisions of this section if
	 it is provided as a result of an emergency.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Determination of emergency hospital care, §
											67:16:03:01.03.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:03 - Outpatient hospital services covered

Current through Register Vol. 51, page 10, July 15, 2024
The following outpatient hospital services covered under the medical
	 assistance program are available to eligible individuals:
(1) Laboratory services;
(2) X ray and other radiology
  services;
(3) Emergency room
  services;
(4) Medical supplies used
  during treatment at the facility;
(5) Physical therapy, speech therapy, and
  occupational therapy when furnished or supervised by a licensed therapist and
  periodically reviewed by a physician or other licensed practitioner;
(6) Whole blood or packed red
  cells;
(7) Drugs and biologicals
  which cannot be self-administered;
(8) Dialysis treatments;
(9) Services of hospital-based physicians or
  other licensed practitioner;
(10)
  Outpatient surgical procedures, including those procedures covered under the
  provisions of chapter 67:16:28;
(11) Sterilizations authorized under §
									67:16:02:09;
(12) Hyperbaric oxygen therapy if the
  requirements listed on the department's prior authorization website are met;
  and
(13) Cardiac rehabilitation -
  Phase II.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
School districts, ch 67:16:37.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:04 - Inpatient hospital services not covered

Current through Register Vol. 51, page 10, July 15, 2024
In addition to other services not specifically listed in §
									67:16:03:02, the following
	 inpatient hospital services are not covered under the medical assistance
	 program:
(1) Physician's services
  other than services by residents and interns in training;
(2) Private duty nursing services;
(3) Personal comfort or convenience
  items;
(4) Any services for organ
  transplants except as authorized under the provisions of chapter
  67:16:31;
(5) Custodial
  care;
(6) Autopsies; and
(7) Chemical dependency or chemical abuse
  treatment services.
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 67:16:03 - Hospital services › Section 67:16:03:06.01 - Basis of reimbursement - Outpatient services other than outpatient laboratory and outpatient surgical procedures

Current through Register Vol. 51, page 10, July 15, 2024
Reimbursement for all outpatient hospital services for Medicare
	 prospective payment system hospitals will be paid using the Medicaid agencys
	 outpatient prospective payment system (OPPS).
Reimbursement for remaining outpatient hospital services for an
	 in-state acute care hospital that had more than 30 inpatient Medicaid
	 discharges in the hospital's fiscal year ending after June 30, 1996, and before
	 July 1, 1997, is adjusted annually for inflation as appropriated by the
	 Legislature and is based on reasonable costs as determined by the hospital's
	 Medicare Cost Report from fiscal year 2010 with the following
	 exceptions:
(1) Costs associated with
  the certified registered nurse anesthetist services that relate to outpatient
  services are included as allowable costs; and
(2) All capital and education costs incurred
  for outpatient services will be included as allowable costs.
Reimbursement for outpatient hospital services for the remaining
	 in-state acute care hospitals is at 90 percent of their usual and customary
	 charge for the service provided.
Reimbursement for out-of-state hospital outpatient services is
	 calculated at a percentage of their usual and customary charge as appropriated
	 by the Legislature.
Costs for outpatient services incurred within three days immediately
	 preceding the inpatient stay are included in the inpatient charges unless the
	 outpatient service is not related to the inpatient stay. This provision applies
	 only if the facilities providing the services are owned by the entity.
Except for Medicare prospective payment system hospitals, outpatient
	 laboratory services are excluded from the provisions of this rule and are
	 payable according to §
										67:16:03:06.07.
Outpatient surgical procedures are payable according to §
										67:16:03:06.11.
For outpatient costs for Medicaid Access Critical facilities the
	 department uses the facility's cost report to determine whether any adjustment
	 to reimbursement is necessary for amounts due the provider.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Medicaid State Plan
, Attachment 4.19-B,
		page 1b. Copies may be obtained from the Department of Social Services,
		Division of Medical Services. 700 Governor's Drive, Pierre, South Dakota
		57501.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:06.02 - Certain in-state hospitals, hospital units, and procedures exempt from DRG basis of reimbursement

Current through Register Vol. 51, page 10, July 15, 2024
In-state freestanding rehabilitation hospitals, public health service
	 hospitals, acute care hospitals with less than 30 Medicaid discharges during
	 their fiscal year ending after June 30, 1996, and before July 1, 1997, and the
	 South Dakota Children's Care Hospital are exempt from DRG reimbursement
	 provisions. The department may exempt in-state intensive care nursery units
	 from DRG reimbursements on request by the hospital if all costs and statistics
	 relating to the operation of the unit are identifiable and if the unit meets
	 the following criteria:
(1) Can
  provide care for infants under 750 grams;
(2) Can provide care for infants on
  ventilators;
(3) Can provide major
  surgery for newborns;
(4) Has
  24-hour coverage by a neonatologist; and
(5) Has a maternal neonatology transport
  team.
The department may exempt a psychiatric unit and a rehabilitation unit
	 from DRG reimbursements on request by the hospital if all costs and statistics
	 relating to the operation of the particular unit are
	 identifiable.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Reimbursement for DRG-exempt hospitals and units, §
											67:16:03:06.06.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:06.03 - Basis of reimbursement - Inpatient services - Hospitals with less than 30 Medicaid discharges

Current through Register Vol. 51, page 10, July 15, 2024
Reimbursement for inpatient hospital services provided by a hospital
	 with less than 30 Medicaid discharges during the hospital's fiscal year ending
	 after June 30, 1996, and before July 1, 1997, is 95 percent of the hospital's
	 usual and customary charge.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Basis of reimbursement -- Inpatient services -- Hospitals with more
		than 30 Medicaid discharges, §
											67:16:03:06.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:06.04 - Basis of reimbursement - Inpatient services - Out-of-state hospitals

Current through Register Vol. 51, page 10, July 15, 2024
The department shall reimburse out-of-state inpatient hospital services
	 by making a prospective payment equal to the payment allowed by the Medicaid
	 program in the state in which the hospital is located. If the Medicaid program
	 in the hospital's home state refuses to price a claim, the payment allowed is a
	 percentage of the provider's usual and customary charge as appropriated by the
	 Legislature.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Medicaid State Plan
, Attachment 4.19-A,
		page 1. Copies may be obtained from the Department of Social Services, Division
		of Medical Services, 700 Governors Drive, Pierre, South Dakota
		57501.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:06.06 - Reimbursement for in-state DRG-exempt hospitals and units

Current through Register Vol. 51, page 10, July 15, 2024
Reimbursement to in-state DRG-exempt hospitals and units is based on
	 reasonable and allowable costs following guidelines established in
	 42 C.F.R. §§
										413.1 to
	 413.157, inclusive, ( August 1,
	 2015), with the following exceptions:
(1) Costs associated with certified
  registered nurse anesthetists that relate to exempt units of hospitals are
  included as allowable costs;
(2)
  Capital and education costs incurred for inpatient services are included as
  allowable costs;
(3) Psychiatric
  unit services are paid at the usual and customary charge for the services
  provided, the daily rate located on the department's fee schedule website, or
  at the rate payable according to §
									67:16:03:06.16, whichever is less.
  The daily rate of payment is subject to review and amendment by the department
  under the provisions of §
									67:16:01:28;
(4) Rehabilitation hospital services are paid
  at the lesser of the usual and customary charge for the services provided or
  the daily rate located on the department's fee schedule website; and
(5) Perinatal units, rehabilitation units,
  and children's care hospitals are reimbursed at a daily rate established by the
  department according to the guidelines provided in the South Dakota Medicaid
  State Plan. The daily rates are located on the department's fee schedule
  website.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2),
		28-6-1.1.
South Dakota Medicaid State Plan
, Attachment 4.19A,
		pages 4-5. Copies may be obtained from the Department of Social Services,
		Division of Medical Services, 700 Governors Drive, Pierre, South Dakota
		57501.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:06.07 - Reimbursement of outpatient laboratory services

Current through Register Vol. 51, page 10, July 15, 2024
Except for Medicare prospective payment system hospitals, outpatient
	 laboratory services are reimbursed according to the outpatient laboratory fee
	 schedule located on the department's fee schedule website. If no fee for a
	 procedure is established, reimbursement is 60 percent of the actual charge for
	 the service.
The laboratory services and associated rates of payment are subject to
	 review and amendment under the provisions of §
									67:16:01:28.
Costs for outpatient laboratory services incurred within three days
	 immediately preceding an inpatient stay are included in the inpatient charges
	 unless the outpatient laboratory service is not related to the inpatient stay.
	 This provision applies only if the facilities providing the services are owned
	 by the same entity.
General Authority:
SDCL
		28-6-1(2),
		28-6-1.1.
Law Implemented:
SDCL
		28-6-1(2),
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:06.08 - Payment for above-average, access-critical and above-average, at-risk hospitals

Current through Register Vol. 51, page 10, July 15, 2024
If the Department of Health determines that a hospital is an
	 above-average, access-critical hospital or an above-average, at-risk hospital,
	 reimbursement is the greater of reasonable costs determined under the
	 provisions of §
									67:16:03:06.01 or the payment
	 otherwise reimbursable under this chapter.
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 67:16:03 - Hospital services › Section 67:16:03:06.09 - Disproportionate share hospitals

Current through Register Vol. 51, page 10, July 15, 2024
To qualify as a disproportionate share hospital, the hospital must meet
	 all of the following requirements:
(1)
  Have a Medicaid inpatient utilization rate that is above the mean Medicaid
  inpatient utilization rate for hospitals receiving Medicaid payments in the
  state or have a low-income utilization rate that exceeds 25 percent. The
  low-income utilization rate is calculated according to
  42 U.S.C. §
										1396r-4 (b)(3), October 1,
  1995;
(2) Have a Medicaid
  utilization rate of at least one percent; and
(3) Have at least two obstetricians who have
  staff privileges at the hospital and have agreed to provide obstetric services
  to individuals eligible for Medicaid. For purposes of this subdivision, an
  obstetrician includes any physician with staff privileges who has agreed to
  perform nonemergency obstetric services to individuals eligible for
  Medicaid.
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 67:16:03 - Hospital services › Section 67:16:03:06.10 - Classification of hospitals providing certain outpatient surgical procedures

Current through Register Vol. 51, page 10, July 15, 2024
Except for Medicare prospective payment system hospitals, if a
	 hospital provides any of the outpatient surgical procedures covered under
	 §
									67:16:28:04, the department shall
	 assign the hospital to one of the following classifications, as
	 applicable:
(1) Class I, a hospital
  which has 60 beds or less;
(2)
  Class II, a hospital which has more than 60 beds; and
(3) Class III, regardless of the number of
  beds, a hospital which is a specialized surgical hospital, is located in a city
  which has an ambulatory surgical center or a specialized surgical hospital, or
  is an out-of-state facility.
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 67:16:03 - Hospital services › Section 67:16:03:06.11 - Basis of reimbursement - Outpatient surgical procedures covered under subdivision 67:16:03:03 (10)

Current through Register Vol. 51, page 10, July 15, 2024
Reimbursement for an outpatient surgical procedure covered under
	 subdivision 67:16:03:03(10) is calculated according to the following:
(1) If the procedure is not covered under
  §
									67:16:28:04, payment is calculated
  according to §
									67:16:03:06.01;
(2) If the procedure is covered under §
									67:16:28:04 and falls into a
  Payment Group of 1, 2, 3, or 4, multiply the payment amount assigned to the
  payment group under §
									67:16:03:06.14 by one of the
  following, as applicable;
(a) If the hospital
  is classified as Class I, 1.25;
(b)
  If the hospital is classified as Class II, 1.10; or
(c) If the hospital is classified as Class
  III, 1.00;
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:06.12 - Services included in reimbursement rate for outpatient surgical procedures covered under chapter 67:16:28

Current through Register Vol. 51, page 10, July 15, 2024
For those outpatient surgical procedures covered under §
									67:16:28:04 that have a payment
	 group of 1, 2, 3, or 4, the rate of reimbursement includes the following
	 services:
(1) Nursing, technician, and
  related services;
(2) Use of the
  outpatient hospital facilities;
(3)
  Supplies, drugs, biologicals, surgical dressings, splinting and casting
  supplies, appliances, and equipment directly related to the provision of the
  services;
(4) Diagnostic or
  therapeutic services or items directly related to the provision of the
  service;
(5) Administrative and
  record-keeping services;
(6)
  Housekeeping items and supplies;
(7) Materials for anesthesia; and
(8) Recovery and observation room charges
  unless the patient is required to stay in excess of 12 hours after the
  completion of the outpatient service.
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 67:16:03 - Hospital services › Section 67:16:03:06.13 - Items and services not included in reimbursement rate for outpatient surgical services covered under chapter 67:16:28 and paid under the provisions of chapter 67:16:03

Current through Register Vol. 51, page 10, July 15, 2024
Outpatient surgical services covered under §
									67:16:28:04 and reimbursed under
	 this chapter do not include items and services for which payment may be made
	 under other provisions of this article, such as physician services, certified
	 registered nurse anesthetist services, laboratory services, X ray or imaging
	 procedures, prosthetic devices, ambulance services, orthotic devices, recovery
	 and observation room charges if the patient is required to stay in excess of 12
	 hours after the completion of the surgical procedure, and durable medical
	 equipment for use in the patient's home, unless they are specifically included
	 under §
									67:16:03:06.12.
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 67:16:03 - Hospital services › Section 67:16:03:06.14 - Payment groups for outpatient hospital surgical procedures covered under chapter 67:16:28

Current through Register Vol. 51, page 10, July 15, 2024
The payments assigned to the different groups of outpatient hospital
	 surgical procedures covered under chapter 67:16:28 are contained on the
	 department's fee schedule website.
The rates of payment for the different groups are subject to review and
	 amendment by the department under the provisions of §
									67:16:01:28.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1,
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:06.15 - Rate of payment - Medicare crossover claims for certain inpatient hospital services

Current through Register Vol. 51, page 10, July 15, 2024
If the department receives a Medicare crossover claim for an inpatient
	 hospital stay and the hospital is subject to the DRG rate of payment, the
	 department shall calculate the DRG payment for the claim based on the date of
	 service. If the amount paid by Medicare is greater than the calculated DRG
	 amount, the department considers the claim to be paid in full and no additional
	 payment will be made by the department. If the amount paid by Medicare is less
	 than the calculated DRG amount, the department shall reimburse the difference
	 between the two payment amounts up to the Medicare inpatient
	 deductible.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Basis of reimbursement -- Inpatient services -- Hospitals with more
		than 30 Medicaid discharges, §
											67:16:03:06.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:06.16 - Rate of reimbursement if individual subject to care management remains in psychiatric unit beyond established discharge date

Current through Register Vol. 51, page 10, July 15, 2024
Reimbursement for services provided in an exempt psychiatric unit on
	 behalf of an individual subject to care management is 50 percent of the per
	 diem rate established in subdivision 67:16:03:06.06(3) if the following
	 requirements are met:
(1) The care
  manager determined that the individual reached the individual's potential in
  the current setting or there is a recommendation through the care conference
  that the individual be transferred to long-term psychiatric care;
(2) The care manager established a discharge
  date;
(3) The care manager provided
  written notice of the established discharge date to the provider; and
(4) Because no alternative placement was
  available, the care manager authorized the individual to remain in the unit
  beyond the established discharge date. This authorization does not constitute a
  change in the established discharge date.
Services provided in an exempt unit that are not authorized by the care
	 manager are not reimbursable.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Authorization for admission required, §
											67:16:40:04; Admission
		requirements -- Psychiatric care, §
											67:16:40:07.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:06.17 - Basis of reimbursement - Inpatient services - Claims containing revenue code 275 or 278

Current through Register Vol. 51, page 10, July 15, 2024
Claims submitted for inpatient hospital services by an in-state acute
	 care hospital that had more than 30 Medicaid discharges during the hospital's
	 fiscal year ending after June 30, 1996, and before July 1, 1997, that are
	 considered to be cost outlier claims as defined by 67:16:03:01(3) and contain
	 revenue code 275 or 278 from the National Uniform Billing Committee Official
	 UB-04 Data Specifications Manual shall be reimbursed according to the following
	 guidelines:
(1) Reimbursement for
  aggregate charges in excess of $ 50,000 associated with revenue code 275 or 278
  is limited to the provider's actual cost plus 10 percent; and
(2) Aggregate charges for revenue code 275 or
  278 in excess of $ 50,000 shall be removed from the calculation of the claim,
  and charges associated with the remainder of the claim shall be reimbursed
  according to §
									67:16:03:06.
The provider shall furnish a copy of the supplier's invoice for items
	 associated with revenue code 275 and 278.
General Authority:
SDCL
		28-6-1(2),
		28-6-1.1.
Law Implemented:
SDCL
		28-6-1(2),
		28-6-1.1.
Official UB-04 Data Specifications Manual 2016, National Uniform
		Billing Committee. Copies may be obtained from the American Hospital
		Association, 155 North Wacker Drive, Suite 400, Chicago, IL 60606;
		$160.00.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:06.18 - Basis of Reimbursement-OPPS

Current through Register Vol. 51, page 10, July 15, 2024
Medicare prospective payment system hospitals will be paid using the
	 Departments OPPS. Under OPPS, services are reimbursed using ambulatory payment
	 classifications. The Department will establish a conversion factor and discount
	 factor specific to each hospital. The hospital specific conversion factor and
	 discount factors are published on the Departments fee schedule.
Outpatient prospective payments do not include items and services for
	 which payment may be made under other provisions of this article, such as
	 physician services, certified registered nurse anesthetist services, prosthetic
	 devices, ambulance services, orthotic devices and durable medical equipment for
	 use in the patient's home, unless they are specifically included in the
	 exception code list on the Departments fee schedule website.
General Authority:
SDCL
		28-6-1(2),
		28-6-1.1.
Law Implemented:
SDCL
		28-6-1(2),
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:07 - Payment of hospital services

Current through Register Vol. 51, page 10, July 15, 2024
Payments to hospitals for services provided to eligible individuals
	 shall be made for medically necessary services provided on an inpatient or
	 outpatient basis and for deductibles and coinsurance under the Medicare
	 program.
A readmission within 72 hours from the time of discharge to the same
	 hospital for a related diagnosis is considered a continuation of the prior
	 admission for payment purposes.
Readmission or return to a hospital following a leave of absence,
	 regardless of length, is not considered a separate admission.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Services not covered, §
											67:16:01:08.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:07.01 - Maximum rate of payment - Transfers between DRG-reimbursed hospital unit and DRG-exempt intensive care nursery unit in same hospital

Current through Register Vol. 51, page 10, July 15, 2024
If an infant is transferred between a DRG-reimbursed hospital unit and
	 a DRG-exempt intensive care nursery unit in the same hospital, the total
	 reimbursement for the combined care in the units may not exceed the amount
	 payable had all of the needed services been delivered in the intensive care
	 nursery unit.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).