reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:11 - Early and periodic screening › Section 67:16:11:03.20 - Private duty nursing services

Current through Register Vol. 51, page 10, July 15, 2024
Private duty nursing services for a technology-dependent individual
	 are covered when the following requirements are met:
(1) The services are medically
  necessary;
(2) The services are
  provided by a nursing agency;
(3)
  The services are provided in the individual's residence, or other setting as
  prior authorized. For the purpose of this rule, an individual's residence does
  not include an intermediate care facility for individuals with intellectual
  disabilities or an institution for individuals with a mental disease, hospital,
  or nursing facility;
(4) The
  services are provided to an individual requiring more patient care than could
  be provided by a home health agency or professional day care when a condition
  or illness would result in institutionalization if not cared for at
  home;
(5) The services are
  prescribed by the individual's attending physician and contained in the
  individual's plan of care; and
(6)
  The services are authorized by the department before they are provided.
The individual's record must contain written documentation verifying
	 that these requirements have been met.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Private duty nursing services -- Extended home health aide services
		--Prior authorization -- Reauthorization, §
											67:16:11:03.22; 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 67:16:11 - Early and periodic screening › Section 67:16:11:03.21 - Extended home health aide services

Current through Register Vol. 51, page 10, July 15, 2024
Extended home health aide services are covered when the following
	 requirements are met:
(1) The services
  are medically necessary;
(2) The
  services are provided to an individual requiring more than three consecutive
  hours of patient care when a condition or illness would result in
  institutionalization if not cared for at home;
(3) The services are provided by a home
  health agency as defined in §
									67:16:05:01;
(4) The services are supervised according to
  §
									67:16:05:05.03; and
(5) The services are authorized by the
  department before they are provided.
The individual's record must contain written documentation verifying
	 that these requirements have been met.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Private duty nursing services -- Extended home health aide services
		-- Prior authorization -- Reauthorization, §
											67:16:11:03.22; 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 67:16:11 - Early and periodic screening › Section 67:16:11:03.22 - Private duty nursing services - Extended home health aide services - Prior authorization - Reauthorization

Current through Register Vol. 51, page 10, July 15, 2024
A provider must have authorization from the department before providing
	 either private duty nursing services or extended home health aide services. The
	 provider must submit to the department a written plan of care which has been
	 reviewed and signed by the attending physician. The department's authorization
	 is based on its review of the required documentation to determine if the
	 conditions for payment have been met. The department may verbally authorize
	 services after the plan of care is submitted; however, the department shall
	 verify a verbal authorization in writing before the services are paid.
An authorization may not exceed two months. The provider may request
	 reauthorization by submitting an updated plan of care and the physician's
	 recertification indicating the need for continued private duty nursing services
	 or extended home health aide 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 67:16:11 - Early and periodic screening › Section 67:16:11:04 - Screening services under EPSDT

Current through Register Vol. 51, page 10, July 15, 2024
A complete, comprehensive screening exam must include the following
	 components:
(1) A comprehensive health
  and developmental history, including an assessment of the physical and mental
  development appropriate for the child's age;
(2) A comprehensive physical exam;
(3) Health education, including anticipatory
  guidance;
(4) Immunizations
  appropriate for age and health history; and
(5) Laboratory tests appropriate for age and
  risk factors.
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 67:16:11 - Early and periodic screening › Section 67:16:11:04.01 - Periodicity schedules for complete, comprehensive screenings

Current through Register Vol. 51, page 10, July 15, 2024
Complete, comprehensive screenings must be completed according to the
	 following schedules:
(1) For
  preventive pediatric healthcare, follow the recommendations adopted by the
  American Academy of Pediatrics (effective February 24, 2014) available at
http://www.aap.org/en-us/professional-resources/practice-support/Pages/PeriodicitySchedule.aspx
.
(2) For immunizations, follow the
  recommendations established by the United States Department of Health and Human
  Services, Center for Disease Control (effective January 1, 2014) available at
http://www.cdc.gov/vaccines/schedules/index.html
;
  and
(3) For dental healthcare, a
  dental screening by a dentist when the child is one year old. After the age of
  one, the dental screenings follow the schedule established under subdivision
  (1) of this section.
Vision, dental, and hearing screenings may be conducted as a portion
	 of the physical exam.
When medically necessary, the screening provider must refer the child
	 to an appropriate specialist for a thorough dental, vision, or hearing
	 exam.
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 67:16:11 - Early and periodic screening › Section 67:16:11:05 - Rate of payment - Screening services

Current through Register Vol. 51, page 10, July 15, 2024
The rate of payment for screening services provided under the EPSDT
	 program is covered under the provisions of chapter 67:16:02 or 67:16:44, as
	 applicable.
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 67:16:11 - Early and periodic screening › Section 67:16:11:05.01 - Rate of payment - Immunizations

Current through Register Vol. 51, page 10, July 15, 2024
Payment for immunizations is limited to the lesser of the provider's
	 usual and customary charge for the immunization provided or the amount
	 specified on the department's fee schedule website.
The rate of payment is subject to review and amendment by the
	 department under the provisions of §
									67:16:01:28.
A provider must obtain the vaccine used for the immunization through
	 the South Dakota Department of Health's Vaccine For Children Program. A list of
	 the available vaccine is located at
	 https://doh.sd.gov/documents/Family/Immunize/EligibilityChart.pdf [File Link
	 Not Available]. Because these vaccines are available free of charge, no payment
	 is allowed for the cost of the vaccine.
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 67:16:11 - Early and periodic screening › Section 67:16:11:06.08 - Rate of payment - Nutritional therapy, nutritional supplements, and electrolyte replacements

Current through Register Vol. 51, page 10, July 15, 2024
Payment for nutritional items and services is made under the provisions
	 of §
									67:16:42:09.
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 67:16:11 - Early and periodic screening › Section 67:16:11:06.09 - Rate of payment - Orthodontic treatment

Current through Register Vol. 51, page 10, July 15, 2024
Payment for orthodontic treatment is limited to the lesser of the
	 provider's usual and customary charge for the covered service provided or the
	 amount specified on the department's fee schedule website.
The rates of payment 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 67:16:11 - Early and periodic screening › Section 67:16:11:06.15 - Rate of payment - Private duty nursing services

Current through Register Vol. 51, page 10, July 15, 2024
Payment for covered private duty nursing services is limited to the
	 lesser of the provider's usual and customary charge or the fee contained on the
	 department's fee schedule website.
The rates of payment 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 67:16:11 - Early and periodic screening › Section 67:16:11:06.16 - Rate of payment - Extended home health aide services

Current through Register Vol. 51, page 10, July 15, 2024
Payment for covered extended home health aide services is limited to
	 the lesser of the provider's usual and customary charge or the fee contained on
	 the department's fee schedule website.
The rates of payment 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 67:16:11 - Early and periodic screening › Section 67:16:11:08.01 - Cost not to exceed long-term institutional care

Current through Register Vol. 51, page 10, July 15, 2024
When the actual or projected cost of all services provided in the home
	 over a period of three months exceeds 135 percent of the cost of care if the
	 individual was institutionalized in a long-term care facility, the department
	 shall issue a notice of intent to discontinue or deny further service. The
	 department shall send the notice to the provider and to the individual. If
	 within 30 days after the notice the provider furnishes documentation that the
	 future service costs in the home will decline and be within 135 percent of the
	 cost of long-term care, the department shall reconsider its
	 decision.
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 67:16:11 - Early and periodic screening › Section 67:16:11:11 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for EPSDT services may be conducted on three
	 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 67:16:11 - Early and periodic screening › Section 67:16:11:13 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
A provider submitting a claim for reimbursement under this chapter must
	 submit the claim at the provider's usual and customary charge.
The laboratory which actually performs the laboratory test must submit
	 the claim for the test.
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 67:16:11 - Early and periodic screening › Section 67:16:11:14 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for services covered under this chapter must be submitted
	 according to the following requirements:
(1) For orthodontic services, follow the
  claim requirements of §
									67:16:11:17;
(2) For private duty nursing, include the
  applicable procedure codes for the covered services provided and follow the
  claim requirements of §
									67:16:11:19.02;
(3) For extended home health aide services,
  include the applicable procedure codes for the covered services provided and
  follow the claim requirements of §
									67:16:11:19.02;
(4) For complete, comprehensive screenings
  and partial screenings, follow the requirements in §
									67:16:02:17;
(5) For nutrition services follow the
  requirements of §
									67:16:42:13; and
(6) For immunizations, follow the
  requirements of §
									67:16:11:19.04.
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 67:16:11 - Early and periodic screening › Section 67:16:11:17 - Claim requirements - Orthodontia services

Current through Register Vol. 51, page 10, July 15, 2024
A claim for orthodontia services provided in 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 payments from this
  charge;
(7) The applicable
  procedure codes for the covered services provided;
(8) The applicable diagnostic diagnosis codes
  adopted in §
									67:16:01:26;
(9) The units of service furnished, if more
  than one;
(10) The provider's name
  and National Provider Identification (NPI) number; and
(11) The prior authorization number.
A separate claim form must be submitted 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 67:16:11 - Early and periodic screening › Section 67:16:11:19.02 - Claim requirements - Private duty nursing - Extended home health aide services

Current through Register Vol. 51, page 10, July 15, 2024
A claim for private duty nursing and extended home health aide
	 services provided in 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 payments from this
  charge;
(7) The applicable
  procedure codes for the covered services provided;
(8) The applicable diagnosis codes adopted in
  §
									67:16:01:26;
(9) The units of service furnished, if more
  than one;
(10) The provider's name
  and National Provider Identification (NPI) number; and
(11) The prior authorization number issued by
  the department. 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.
Claims, ch 67:16:35.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:11 - Early and periodic screening › Section 67:16:11:19.03 - Claim requirements - Screenings

Current through Register Vol. 51, page 10, July 15, 2024
A claim for screening 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) The
  third-party liability information required under chapter 67:16:26;
(4) The date of service;
(5) The applicable procedure codes for the
  covered services provided; and
(6)
  The provider's name and national provider identification number.
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 67:16:11 - Early and periodic screening › Section 67:16:11:19.04 - Claim requirements - Immunizations

Current through Register Vol. 51, page 10, July 15, 2024
A claim for immunization 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) The
  third-party liability information required under chapter 67:16:26;
(4) The date of service;
(5) The applicable procedure codes for the
  covered services provided; and
(6)
  The provider's name and national provider identification number.
A separate claim must be submitted 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 67:16:11 - Early and periodic screening › Section 67:16:11:20 - 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 67:16:11 - Early and periodic screening › Appendix C - List of Procedure Codes and Prices for Orthodontic Services, repealed, 35 SDR 88, effective October 23, 2008

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 67:16:12 - Family planning services › Section 67:16:12:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Family planning services," medically
  approved services and supplies which are available for individuals of
  childbearing age for the purpose of providing freedom of choice to determine,
  in advance, the number and spacing of children.
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 67:16:12 - Family planning services › Section 67:16:12:02 - Scope of services

Current through Register Vol. 51, page 10, July 15, 2024
Pursuant to SDCL
	 28-6-4, the department may provide
	 the following family planning services to eligible individuals:
(1) Diagnosis;
(2) Treatment;
(3) Drugs, supplies, devices, and procedures,
  except agents to promote fertility; and
(4) Related counseling under the supervision
  of a physician or other licensed practitioner.
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 67:16:12 - Family planning services › Section 67:16:12:02.01 - Services not covered

Current through Register Vol. 51, page 10, July 15, 2024
The following services are not covered:
(1) Agents to promote fertility;
(2) Procedures to reverse a previous
  sterilization;
(3) Removal of
  implanted contraceptive capsules if done to reverse the intent of the original
  implant; and
(4) Artificial
  insemination.
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 67:16:12 - Family planning services › Section 67:16:12:03 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
The department shall make payments according to the applicable
	 provisions of chapters 67:16:01, 67:16:02, 67:16:03, 67:16:05, 67:16:13,
	 67:16:14, 67:16:28, and 67:16:44 for services provided 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 67:16:12 - Family planning services › Section 67:16:12:04 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
The department may conduct utilization reviews for family planning
	 services on the following levels:
(1)
  Computerized claims processing;
(2)
  Postpayment review; and
(3) Peer
  reviews.
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 67:16:12 - Family planning services › Section 67:16:12:05 - Billing requirements

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 and in accordance with the applicable
	 provisions of chapters 67:16:01, 67:16:02, 67:16:03, 67:16:05, 67:16:13,
	 67:16:14, 67:16:28, and 67:16:44.
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 67:16:12 - Family planning services › Section 67:16:12:06 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for services covered under §
									67:16:12:02 must be submitted
	 according to the following:
(1) If the
  claim relates to a physician's service, follow the claim requirements of
  chapter 67:16:02;
(2) If the claim
  relates to hospital services, follow the claim requirements of chapter
  67:16:03;
(3) If the claim relates
  to home health services, follow the claim requirements of chapter
  67:16:05;
(4) If the claim relates
  to clinic services, follow the claim requirements of chapter
  67:16:13;
(5) If the claim relates
  to prescription drugs, follow the claim requirements of chapter
  67:16:14;
(6) If the claim relates
  to ambulatory surgical center services, follow the claim requirements of
  chapter 67:16:28; and
(7) If the
  claim relates to federally qualified health centers and rural health clinic
  services, follow the claim requirements of chapter 67:16:44.
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 67:16:12 - Family planning services › Section 67:16:12:07 - 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 67:16:13 - Community Mental Health Center Services › Section 67:16:13:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter, unless the context plainly requires
	 otherwise, mean:
(1) "Community mental
  health center," any facility organized to provide outpatient mental health
  services and approved by the state approving agency of the state in which it is
  located that has a psychiatrist on staff as the medical director of the
  center;
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 67:16:13 - Community Mental Health Center Services › Section 67:16:13:03 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment to a community mental health center is limited to the
	 providers usual and customary charge or the fee contained on the departments
	 fee schedule website, whichever is less.
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 67:16:13 - Community Mental Health Center Services › Section 67:16:13:04 - Covered services

Current through Register Vol. 51, page 10, July 15, 2024
To be covered, services must be provided by an agency who meets the
	 requirements of chapter 67:62:02. Covered services are limited to the services
	 described in chapters 67:62:10, 67:62:11, 67:62:12, and
	 67:62:13.
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 67:16:13 - Community Mental Health Center Services › Section 67:16:13:05

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 67:16:13 - Community Mental Health Center Services › Section 67:16:13:06 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for mental health center and clinic services may be
	 conducted on the following levels:
(1)
  Computerized claims processing;
(2)
  Postpayment review; and
(3) Peer
  reviews.
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 67:16:13 - Community Mental Health Center Services › Section 67:16:13:07

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Cost-sharing participants, §
											67:16:01:22.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:13 - Community Mental Health Center Services › Section 67:16:13:08 - Billing requirements

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.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Third-party liability, ch
		67:16:26.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:13 - Community Mental Health Center Services › Section 67:16:13:09 - 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) 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) The
  applicable procedure codes contained in either
Health Care Common
  Procedure Coding System
(HCPCS) or
Current Procedural
  Terminology
(CPT) for services covered under this chapter;
(8) The applicable diagnosis codes adopted in
  §
									67:16:01:26;
(9) The units of service furnished, if more
  than one;
(10) The billing
  provider's name and National Provider Identification (NPI) number;
  and
(11) 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.
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 67:16:13 - Community Mental Health Center Services › Section 67:16:13:10 - 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 67:16:14 - Prescription drugs › Section 67:16:14:02.01 - PHS provider identification number

Current through Register Vol. 51, page 10, July 15, 2024
A PHS provider must have a PHS provider agreement with the department.
	 In addition to the provider identification number assigned under the provisions
	 of §
									67:16:33:02, the department shall
	 assign a PHS provider a PHS provider identification number. The PHS provider
	 must include the PHS provider identification number on those claims submitted
	 under the provisions of the PHS provider agreement.
The PHS provider agreement is subject to the requirements contained in
	 chapter 67:16:33.
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 67:16:14 - Prescription drugs › Section 67:16:14:04 - Items and services covered

Current through Register Vol. 51, page 10, July 15, 2024
A prescription is required for all of the items and services and
	 nonlegend drugs and supplies covered under this section. The following
	 prescription drugs, biologicals, and related items and services are covered
	 under this chapter:
(1) Legend eye
  preparations, vaginal therapeutics, otic pharmaceutical preparations, or
  inhalations for asthmatic conditions;
(2) Antibiotic products which are known,
  either by sensitivity test or product information, to be the single item of
  choice for the diagnosis;
(3) All
  other legend prescription drugs and biologicals, except for the items listed in
  §
									67:16:14:05;
(4) Insulin;
(5) Concentrated cryoprecipitate used in the
  home treatment of hemophilia;
(6)
  Legend vitamins prescribed for the prenatal care of pregnant women;
(7) Calcitriol if used for renal impairment
  and determined medically necessary by the prescriber;
(8) Spacers, such as Aerochamber and
  InspirEase, and solutions that are medically necessary for the administration
  of legend drugs used for the delivery of respiratory or inhalation
  therapy;
(9) Syringes and needles
  for the administration of medication covered under this chapter;
(10) Urine and blood testing items for a
  diabetic, except for glucometers which are covered under the provisions of
  chapter 67:16:29; and
(11) The OTC
  items recommended for coverage by the P and T committee and approved for
  coverage by the department.
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 67:16:14 - Prescription drugs › Section 67:16:14:05 - Items and services not covered

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the items and services not specifically listed in §
									67:16:14:04, the following items
	 and services are not covered under this chapter:
(1) Nonlegend prescription drugs and
  over-the-counter items and medical supplies except for those items covered
  under §
									67:16:14:04;
(2) Medical supplies or delivery
  charges;
(3) Legend oral vitamins
  except for legend vitamins prescribed for the prenatal care of pregnant women
  covered under §
									67:16:14:04;
(4) Nicotine patches and other nicotine
  replacement products;
(5) Agents to
  promote fertility or treat impotence;
(6) Agents used for cosmetic
  purposes;
(7) Hair growth
  products;
(8) Items or drugs
  manufactured by a firm that has not signed a rebate agreement with the United
  States Department of Health and Human Services, Centers for Medicare and
  Medicaid Services;
(9) Items which
  exceed a 34-day supply, except for 90 day fills on select generic maintenance
  medications, family planning items, and prenatal vitamins;
(10) Services, procedures, or drugs which are
  considered experimental, not including services, procedures, or drugs approved
  by the Food and Drug Administration under an emergency use authorization that
  are being utilized in accordance with the emergency use
  authorization;
(11) Drugs and
  biologicals which the federal government has determined to be less than
  effective according to Pub. L. No. 97-35, § 2103 (August 13, 1981), 95
  Stat. 787; and
(12) Drugs that did
  not receive prior authorization from the department under the provisions of
  this chapter.
General Authority:
SDCL
		28-6-1(1)(2).
Law Implemented:
SDCL
		28-6-1.
Reimbursement for prescribed drugs -- Signed rebate agreement
		required, Pub. L. No. 101-508, § 4401.
Information about drugs which have been determined to be less than
		effective is available at
https://data.medicaid.gov/Drug-Pricing-and-Payment/Drug-Products-in-the-Medicaid-Drug-Rebate-Program/v48d-4e3e/data
.
A list of drugs that require prior approval is available at
https://prdgov-rxadmin.optum.com/rxadmin/SDM/Prior_authorization.html
.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:14 - Prescription drugs › Section 67:16:14:06 - Payment for items dispensed by pharmacy

Current through Register Vol. 51, page 10, July 15, 2024
Payment for items covered under this chapter and dispensed by a
	 pharmacy is made at the lowest of the following: The provider's usual and
	 customary charge;
(1) The estimated
  acquisition cost of the drug dispensed, plus a dispensing fee contained on the
  department's fee schedule website;
(2) The payment limit established by the
  United States Department of Health and Human Services under the provisions of
  42 C.F.R. § 447.332 (July 1, 1987) for multiple-source drugs, plus a
  dispensing fee contained on the department's fee schedule website; or
(3) The payment limit established by the
  department, in consultation with the contractor, for drugs contained on the
  state MAC list, plus a dispensing fee contained on the department's fee
  schedule website.
For purposes of this section, the provider's usual and customary charge
	 is that charge made by the provider to third-party payers for a specific item
	 on the day the item is supplied.
General Authority:
SDCL
		28-6-1,
		28-6-1.1.
Law Implemented:
SDCL
		28-6-1,
		28-6-1.1.
Upper limits for multiple-source drugs, 42 C.F.R. § 447.332 .
		Payment for drugs dispensed by physician, § 67:16:14:06.06. Payment for
		drugs dispensed by PHS provider, § 67:16:14:06.09. Federal drug list,
http://www.cms.hhs.gov/home/medicaid.asp
.
		State MAC list, Departments pharmacy
		website.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:14 - Prescription drugs › Section 67:16:14:06.02 - State MAC list

Current through Register Vol. 51, page 10, July 15, 2024
Drugs covered under the state MAC list are limited to those drugs that
	 are widely and consistently available to South Dakota pharmacies at a price
	 that is less than the consolidated price. The department, in consultation with
	 the contractor, shall determine which drugs to place on the state MAC list and
	 shall establish the maximum allowable price for each drug contained on the
	 list. The maximum allowable price for each drug is based on the cost at which
	 the drug is available to South Dakota pharmacy providers. The department, in
	 consultation with the contractor, shall review the state MAC list and the
	 associated maximum allowable prices at least monthly.
The department, in consultation with the contractor, shall update the
	 state MAC list when the department receives information from the contractor
	 that the price for a specific drug has changed or a drug is now available or is
	 no longer available to South Dakota pharmacies at a price less than the
	 consolidated price. In addition, a pharmacist may request that the list be
	 amended. To request an amendment to the list, the pharmacist must contact the
	 Department of Social Services, Office of Medical Services. The pharmacist must
	 specify the reason for the requested change. When considering the request, the
	 department shall consult with the contractor to confirm the price change. When
	 the department takes final action on the requested change, the department shall
	 notify the pharmacist who made the request. The department shall notify
	 participating providers of changes made to the list.
Payment for drugs located on the state MAC price list is limited to the
	 amount specified on the list unless subdivision 67:16:14:06(1) or (2) is lower.
	 The state MAC list is on the departments pharmacy website.
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 67:16:14 - Prescription drugs › Section 67:16:14:06.03 - Dispensing fee for maintenance drugs

Current through Register Vol. 51, page 10, July 15, 2024
Dispensing fee payments for maintenance drugs or items are limited to
	 one each month for each drug or item except for the following:
(1) Schedule II, III, and IV controlled
  substances;
(2)
  Clozapine;
(3) Antipsychotic drugs
  for recipients who are not institutionalized if the physician or other licensed
  practitioner indicates on the prescription that a month's supply of the drug is
  not in the patient's best interests and that the quantities may not be
  increased;
(4) Liquid products,
  ointments, or biologicals dispensed in their original containers if the product
  is not available from the manufacturer in a container which is adequate for a
  one-month's supply; and
(5) Drugs
  that must be dispensed in smaller quantities to ensure the stability and
  effectiveness of the drug.
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 67:16:14 - Prescription drugs › Section 67:16:14:06.04 - Payment of container costs for drugs dispensed under unit dose system

Current through Register Vol. 51, page 10, July 15, 2024
Payment for drugs dispensed under a unit dose system includes a
	 container cost in addition to the amount determined under §
									67:16:14:06. The container cost is
	 available on the department's pharmacy website and is limited to one fee for
	 each prescription each month.
Manufacturers' prepackaged strip items, liquid preparations, or items
	 dispensed in original containers do not qualify for additional container
	 costs.
Payment for drugs dispensed under a unit dose system is limited to a
	 recipient who is a participant under home- and community-based services or
	 resides in a nursing facility, an intermediate care facility for individuals
	 with intellectual disabilities, an assisted living center, or an adjustment
	 training center.
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 67:16:14 - Prescription drugs › Section 67:16:14:06.05 - Prescriptions for family planning items

Current through Register Vol. 51, page 10, July 15, 2024
An initial prescription for a family planning item may be dispensed in
	 less than a three-month supply until maintenance is established. Once
	 maintenance is established, the item must be dispensed in at least a
	 three-month supply and, if prescribed by the physician or other licensed
	 practitioner, may be dispensed in a 12-month supply.
For purposes of this rule, the term "maintenance" means that the
	 medication has been dispensed three times in the same strength, regardless of
	 dosage schedule, in any combination of brand name or generic
	 form.
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 67:16:14 - Prescription drugs › Section 67:16:14:06.06 - Payment for drugs dispensed by physician

Current through Register Vol. 51, page 10, July 15, 2024
Payment for items covered under this chapter and dispensed by a
	 physician or other licensed practitioner is made according to one of the
	 following:
(1) If a pharmacy is not
  available in the provider's service area, payment is made according to §
									67:16:14:06;
(2) If a pharmacy is available in the
  provider's service area, payment is limited to the provider's cost of the item;
  or
(3) If the physician is a PHS
  provider and the drug being dispensed is covered under the PHS program, payment
  is made according to §
									67:16:14:06.09.
If submitting a claim for services provided under subdivision (2) or
	 (3) of this section, the physician or other licensed practitioner must maintain
	 a copy of the supplier's invoice showing the actual cost of the item to the
	 provider. At the department's request, the provider must furnish a copy of the
	 invoice to substantiate the claim.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Definition of "cost," §
											67:16:14:01.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:14 - Prescription drugs › Section 67:16:14:06.09 - Payment for items dispensed by PHS provider

Current through Register Vol. 51, page 10, July 15, 2024
Except for family planning supplies, payment for items dispensed by a
	 PHS provider is limited to the cost of the item plus $4.30 or three percent,
	 whichever is greater. Family planning supplies are payable under the provisions
	 of §
									67:16:14:06.
The dispensing PHS provider must maintain a copy of the supplier's
	 invoice showing the actual cost of the items to the PHS provider. At the
	 department's request, the PHS provider must furnish a copy of the invoice to
	 substantiate the claim.
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 67:16:14 - Prescription drugs › Section 67:16:14:06.10 - Coverage limits - Growth hormones

Current through Register Vol. 51, page 10, July 15, 2024
Growth hormones are covered when the use of the drug has received
	 prior authorization from the department. Either the prescribing physician,
	 other licensed practitioner, or the pharmacist must complete the prior
	 authorization form which is available from the department. Authorization for
	 payment is based on diagnosis and medical necessity. The department will
	 respond to the request for prior authorization within one business day after
	 receiving the completed form.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Covered services must be medically necessary, §
											67:16:01:06.02.