reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:02.02

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 67:16:29 - Medical equipment › Section 67:16:29:02.03

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 67:16:29 - Medical equipment › Section 67:16:29:02.04

Current through Register Vol. 51, page 10, July 15, 2024
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 67:16:29 - Medical equipment › Section 67:16:29:02.05

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 67:16:29 - Medical equipment › Section 67:16:29:02.06

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Limits on the provision of medical equipment, §
											67:16:29:04.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:02.07

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 67:16:29 - Medical equipment › Section 67:16:29:02.08

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 67:16:29 - Medical equipment › Section 67:16:29:02.09

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 67:16:29 - Medical equipment › Section 67:16:29:02.10

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Assistive devices, SDCL ch
		37-31.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:02.11

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:03 - Maintenance and repair of medical equipment

Current through Register Vol. 51, page 10, July 15, 2024
Payment for the maintenance and repair of medical equipment is covered
	 when:
(1) The item is covered by South
  Dakota Medicaid;
(2) The recipients
  condition meets the coverage criteria for the item; and
(3) The item is owned by the recipient.
Payment for the maintenance and repair of medical equipment is not
	 allowed if the equipment is owned by the nursing facility or someone other than
	 the recipient.
The cost of repair may not exceed the purchase price of the new item.
	 The cost of a repair to medical equipment that is under a warranty is not
	 eligible for payment if the repair is covered by warranty. Providers must keep
	 a copy of the warranty. The warranty must be provided upon request of the
	 department. Repairs or maintenance due to malicious damage or culpable neglect
	 shall be referred to the Department for review.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
Basis of payment, §
											67:16:29:07.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:04 - Limits on the provision of medical equipment and supplies

Current through Register Vol. 51, page 10, July 15, 2024
The provision of medical equipment and supplies is subject to the
	 following requirements:
(1) The
  equipment and supplies must be medically necessary according to §
									67:16:01:06.02;
(2) The equipment and supplies must be
  prescribed in writing by a physician or other licensed practitioner for use in
  the recipient's residence. A recipient's residence does not include a nursing
  facility, an intermediate care facility for individuals with intellectual
  disabilities, or an institution for individuals with a mental
  disease;
(3) The prescription must
  be signed and dated by the physician or other licensed practitioner before the
  covered medical equipment is provided. The effective date of the prescription
  is the physician or other licensed practitioner's signature date; and
(4) When equipment is rented, the initial
  prescription is valid for no more than one year and must be renewed annually
  thereafter, unless the quantity, frequency, or duration of the recipient's
  need, as estimated by the physician or other licensed practitioner, has expired
  prior to the annual renewal. Documentation justifying continued use of rental
  equipment must be included in the medical record.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:04.01 - Equipment not covered

Current through Register Vol. 51, page 10, July 15, 2024
The following are not considered medical equipment or medical supplies
	 and are not covered due to not meeting the definitions in §
									67:16:29:01:
(1) Self-help devices. A self-help device is
  equipment that neither corrects nor improves a condition, but provides
  assistance to the user, such as bathtub or shower safety rails;
(2) Exercise equipment;
(3) Protective outerwear;
(4) Book bags, stairway elevator chairs, or
  other convenience items;
(5) Air
  conditioners, humidifiers, dehumidifiers, heaters, furnaces, or other personal
  comfort or environmental control equipment;
(6) Tumble form roll and other items not used
  primarily for medical purposes;
(7)
  Computers, hook-ups to a computer system, or a computer printer, except for
  augmentative communication devices that meet the requirements listed on the
  department's billing guidance website;
(8) First-aid or precautionary-type
  equipment; and
(9) Training
  equipment, such as speech teaching machines, braille training texts.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Payment to States,
		42 U.S.C. §
												1396b (July 1,
		2019).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:04.02 - Provider to maintain records

Current through Register Vol. 51, page 10, July 15, 2024
The provider prescribing medical equipment must document the medical
	 necessity in the recipient's clinical record. Unless otherwise specified in the
	 department's coverage criteria, documentation of medical necessity must be
	 updated annually or when the physician or other licensed practitioner's
	 estimated quantity, frequency, or duration has changed prior to the annual
	 renewal. Failure to properly document medical necessity is cause for
	 nonpayment.
The clinical record must contain:
(1) Recipient name and Medicaid ID
  number;
(2) Diagnosis, including an
  explanation of the particular condition resulting from the diagnosis which
  relates to the equipment request;
(3) Prognosis;
(4) Length of time the item is expected to be
  required;
(5) Justification of
  medical necessity;
(6) Equipment
  prescribed;
(7) Prescribing
  provider's National Provider Identification (NPI) number, signature, and date
  signed;
(8) Description of
  equipment; and
(9) Explanation of
  equipment functions.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:05 - Rental or purchase at department's discretion - Ownership of purchased equipment

Current through Register Vol. 51, page 10, July 15, 2024
Covered equipment may be rented or purchased at the discretion of the
	 department. In exercising its discretion, the department shall use the
	 following guidelines to determine the most cost-effective method of
	 payment:
(1) Items required for a
  short time, such as six months or less, will normally be rented;
(2) Equipment required for longer periods
  will normally be purchased; and
(3)
  Equipment costing less than $120 will normally be purchased.
The department may negotiate with any equipment provider to obtain the
	 most cost-effective rental or purchase price for covered equipment requiring
	 prior authorization.
Medical equipment purchased under this chapter becomes the property of
	 the recipient.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
Pressure reduction therapy -- Limits, §
											67:16:29:02.01.
Lymphedema pumps -- Limits, §
											67:16:29:02.05.
Augmentative communication device -- Modification -- Prior
		authorization -- Required documentation, §
											67:16:29:02.07.
Medical equipment -- EPSDT, §
											67:16:11:03.18.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:06 - Rental payments applied to purchase

Current through Register Vol. 51, page 10, July 15, 2024
When equipment is rented, the rental payments must be applied toward
	 the allowable purchase price of the equipment. The department shall consider
	 the equipment purchased when 12 rental payments have been made without a break
	 in rental payments of three or more consecutive months. A new rental period
	 begins when a break in rental payments of three or more consecutive months
	 occurs. If the total of the 12 rental payments is less than the allowable
	 purchase price of the equipment, the department shall consider the equipment
	 purchased when the total rental payments equal the allowable purchase price. In
	 either case, once the equipment is purchased, the provider may not submit an
	 additional claim for payment of the equipment purchased.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:06.01 - Conditions under which rental equipment no longer covered

Current through Register Vol. 51, page 10, July 15, 2024
Rental equipment is no longer covered when any of the following
	 conditions exist:
(1) The prescription
  for the equipment is not valid;
(2)
  The equipment has been returned to the provider; or
(3) The recipient is no longer using the
  equipment.
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 67:16:29 - Medical equipment › Section 67:16:29:07 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment for the purchase or the monthly rental of medical equipment
	 covered under this chapter is limited to the lesser of the provider's usual and
	 customary charge or the fee established on the department's fee schedule
	 website. If no fee is established, payment will be 75 percent of the provider's
	 usual and customary charge. Payment for the purchase or monthly rental of
	 medical equipment includes the following:
(1) The manufacturer and dealer
  warranty;
(2) Any cost associated
  with assembling an item or part used for the assembly of an item;
(3) Any adjustment and modification required
  within 90 days of the dispensing date for purchases or during the total rental
  period, except those due to a major change in the recipients
  condition;
(4) Instruction to the
  recipient in the safe use of the medical equipment;
(5) Cost of delivery to the recipients
  residence and, when appropriate, to the room in which the item will be used;
  and
(6) Cost of return to the
  provider if rented.
Payment for supplies necessary for the effective use or proper
	 functioning of covered medical equipment is 90 percent of the provider's usual
	 and customary charge or the fee established on the department's fee schedule
	 website.
Payment for equipment maintenance and repairs is the lesser of the
	 provider's usual and customary charge or the purchase price of a new piece of
	 equipment. Purchase price is established according to this section.
Payment may not exceed billed charges.
The equipment and associated rates of payment are subject to review and
	 amendment under the provisions of §
										67:16:01:28.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2),
		28-6-1.1.
Rental payments applied to purchase, §
											67:16:29:06.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:08

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 67:16:29 - Medical equipment › Section 67:16:29:09 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
Claims for medical equipment must be submitted at the provider's usual
	 and customary charge. If it is the provider's custom to charge the general
	 public for handling, delivery, and taxes, those charges may be included in the
	 provider's usual and customary charge. A provider may not bill the department
	 for equipment until the equipment has been delivered to the recipient.
A copy of the physician or other licensed practitioner's written
	 prescription, the invoice showing the purchase price of the equipment, and
	 other documentation does not need to be submitted with the claim unless
	 required; however, it must be maintained by the provider in the recipient's
	 clinical record and made available on request.
Covered equipment must be billed using the applicable procedure code
	 contained in Health Care Common Procedure Coding System (HCPCS).
A provider may not submit claims that do not meet the criteria
	 contained in this chapter.
A provider may not submit a claim for hearing aids until after thirty
	 days of placement. A provider may not submit a claim if the hearing aids are
	 returned during a trial period.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2)(4),
		28-6-1.1.
Claim requirements, §
											67:16:29:11.
Use of Health Care Common Procedure Coding System, §
											67:16:01:27.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:10 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for medical equipment may be conducted during
	 computerized claims processing and postpayment 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 67:16:29 - Medical equipment › Section 67:16:29:11 - 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) The
  applicable procedure codes contained in either
CMS Common Procedure
  Coding System (HCPCs)
or the
Physicians' Current Procedural
  Terminology (CPT)
for services covered under this chapter;
(8) The units of service furnished, if more
  than one;
(9) The provider's name
  and National Provider Identification (NPI) number;
(10) The ordering providers NPI
  number;
(11) The prior
  authorization number issued by the department for services requiring prior
  authorization;
(12) One of the
  following modifier codes, as applicable, at the end of the procedure code:
(a) LL - Lease/rental, when rental is to be
  applied to the purchase price;
(b)
  NU - New equipment;
(c) RP -
  Replacement and repair;
(d) RR -
  Rental, when medical equipment is to be rented; or
(e) UE - Used medical equipment.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:12 - 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 67:16:31 - Organ transplants › Section 67:16:31:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Roentgenographic," a record of the
  internal structures of the body made by passing X rays through the body to act
  on specially sensitized film;
(2)
  "Severe hemodynamic compromise," severe compromise of the movements involved in
  the circulation of blood; and
(3)
  "Vital end-organ" or "Major end-organ," one of the larger encapsulated endings
  of the sensory nerves necessary to life.
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 67:16:31 - Organ transplants › Section 67:16:31:02 - Organ transplants covered

Current through Register Vol. 51, page 10, July 15, 2024
Kidney transplants and cornea transplants are covered for adults. Other
	 nonexperimental organ transplant procedures are covered for adults if prior
	 authorization is obtained from the department.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:31 - Organ transplants › Section 67:16:31:02.01 - Liver transplants limited to certain centers

Current through Register Vol. 51, page 10, July 15, 2024
Liver transplant services must be performed at a Medicare-approved
	 transplant center or a transplant center approved by the Organ Procurement and
	 Transplantation Network (OPTN).
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
List of Medicare-approved transplant facilities,
		https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/ApprovedTransplantPrograms.pdf.
		List of Organ Procurement and Transplantation Network approved transplant
		centers,
https://optn.transplant.hrsa.gov/members/member-directory/?memberType=Transplant
Centers
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:31 - Organ transplants › Section 67:16:31:04 - Heart transplants limited to certain centers

Current through Register Vol. 51, page 10, July 15, 2024
Heart transplant services must be performed at a Medicare-approved
	 transplant center.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
List of Medicare-approved transplant facilities,
http://www.cms.hhs.gov/ApprovedTransplantCenters/
.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:31 - Organ transplants › Section 67:16:31:05 - Individuals eligible for Medicare must apply to Medicare

Current through Register Vol. 51, page 10, July 15, 2024
Individuals eligible for Medicare must apply to Medicare for coverage
	 of any proposed transplant. A decision by Medicare that a transplant would not
	 be covered by the Medicare program because the individual fails to meet the
	 Medicare patient selection criteria is binding on the medical assistance
	 program.
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 67:16:31 - Organ transplants › Section 67:16:31:06 - Transplants limited to human organs

Current through Register Vol. 51, page 10, July 15, 2024
Only human organs may be used for transplants covered 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 67:16:31 - Organ transplants › Section 67:16:31:07 - Expenses for transplant donors

Current through Register Vol. 51, page 10, July 15, 2024
Covered medical expenses for transplant donors are limited to the
	 donor's hospitalization, physician, and laboratory fees.
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 67:16:31 - Organ transplants › Section 67:16:31:08 - Donated funds

Current through Register Vol. 51, page 10, July 15, 2024
Money donated on behalf of an individual as the result of fund drives
	 or other community fund-raising activities for the purpose of assisting with
	 the costs associated with a transplant must be applied to the payment for the
	 recipient's medical care after deductions for travel to and from medical
	 facilities.
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 67:16:31 - Organ transplants › Section 67:16:31:09 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment for services covered under this chapter is limited to the
	 amounts allowed in chapters 67:16:02 and 67:16:03.
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 67:16:31 - Organ transplants › Section 67:16:31:10 - 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 must contain the appropriate
	 procedures codes contained in chapters 67:16:02 and 67:16:03.
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 67:16:31 - Organ transplants › Section 67:16:31:11 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for organ transplants may be conducted on the
	 following levels:
(1) Computerized
  claims processing;
(2) Postpayment
  review; and
(3) Peer
  review.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:31 - Organ transplants › Section 67:16:31:12 - 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 67:16:33 - Provider requirements › Section 67:16:33:02 - Participating provider

Current through Register Vol. 51, page 10, July 15, 2024
To receive reimbursement for covered medical services which are
	 medically necessary and which are provided to eligible recipients, a provider
	 must have a provider agreement with the department. The agreement must be
	 signed by the individual who is requesting to become a participating provider
	 or by an agent of the facility or corporation that is requesting to become a
	 participating provider and approved and signed by the department. Only those
	 individuals or facilities which meet licensure and certification requirements
	 listed in this article may be participating providers.
Upon department approval, the department shall notify the provider in
	 writing of the effective date of the agreement and the provider identification
	 number. Under an approved provider agreement, the participating provider agrees
	 to submit claims only for those services or supplies which meet the
	 requirements of this article, are within the provider's service limits listed
	 in this article, are medically necessary, and are actually furnished to an
	 eligible recipient on or after the effective date of the provider agreement.
	 The department may terminate a provider agreement if the participating provider
	 fails to meet any of these requirements.
An agreement with a participating provider does not become effective
	 until the department has approved and signed the agreement. A provider may not
	 request reimbursement for covered services provided before the effective date
	 of the provider agreement.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Covered services must be medically necessary, §
											67:16:01:06.02; Duration of
		agreement, §
											67:16:33:04.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:33 - Provider requirements › Section 67:16:33:03 - Provider agreements limited to providers who provide a covered service

Current through Register Vol. 51, page 10, July 15, 2024
The department may enter into a provider agreement only with those
	 providers who provide a service covered under this article.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Participating provider, §
											67:16:33:02.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:33 - Provider requirements › Section 67:16:33:04 - Duration of agreement

Current through Register Vol. 51, page 10, July 15, 2024
A provider agreement remains in effect until one of the following
	 occurs:
(1) The agreement
  expires;
(2) The provider fails to
  comply with conditions of the signed provider agreement or conditions of
  participation;
(3) The ownership,
  assets, or control of the provider's entity are sold or transferred;
(4) Thirty days elapse since the department
  requested the provider to sign a new provider agreement;
(5) The provider requests termination of the
  agreement;
(6) Thirty days elapse
  since the department provided written notice to the provider of its intent to
  terminate the agreement;
(7) The
  provider is convicted of a criminal offense that involves fraud in any state or
  federal medical assistance program;
(8) The provider is suspended or terminated
  from participating in Medicare;
(9)
  The provider's license or certification is suspended or revoked; or
(10) The provider fails to comply with the
  requirements and limits of this article.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Participating provider, §
											67:16:33:02.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:33 - Provider requirements › Section 67:16:33:05 - Individuals providing services under another provider's agreement

Current through Register Vol. 51, page 10, July 15, 2024
An individual who does not have a provider agreement but who furnishes
	 a covered service to a recipient under another provider's agreement and
	 receives payment or benefits indirectly from the department is subject to the
	 requirements of this article.
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 67:16:33 - Provider requirements › Section 67:16:33:06 - Disclosure requirements

Current through Register Vol. 51, page 10, July 15, 2024
A provider must disclose information on ownership, control interest,
	 and convictions as required by 42 C.F.R. § 455, Subpart B (October 1,
	 1989).
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 67:16:33 - Provider requirements › Section 67:16:33:07 - Sale or transfer of entity

Current through Register Vol. 51, page 10, July 15, 2024
A participating provider who sells or transfers ownership or control of
	 the entity must give the department written notice of the pending sale or
	 transfer at least 30 days before the effective date.
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 67:16:33 - Provider requirements › Section 67:16:33:08 - Licensing or certification changes

Current through Register Vol. 51, page 10, July 15, 2024
The participating provider must notify the department in writing of any
	 change in the provider's licensing or certification status. Notification must
	 be made within ten days after the provider receives notification of the change
	 in status.
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 67:16:33 - Provider requirements › Section 67:16:33:09 - Application of chapter

Current through Register Vol. 51, page 10, July 15, 2024
The rules in this chapter apply to all enrolled providers and
	 recipients.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:34 - Records › Section 67:16:34:02 - Maintenance of medical and financial records

Current through Register Vol. 51, page 10, July 15, 2024
Providers must keep legible medical and fiscal records that fully
	 justify and disclose the extent of services provided and the billings made to
	 the department.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:34 - Records › Section 67:16:34:03 - Required medical records

Current through Register Vol. 51, page 10, July 15, 2024
A provider must maintain a medical record on each recipient which
	 discloses the extent of services furnished under this article. Each page of the
	 record must name or otherwise identify the recipient and each entry in the
	 record must be signed and dated by the individual providing the care. If care
	 is provided by one individual who is working under the supervision of another
	 who is a participating provider, the supervising individual must countersign
	 each entry. If the care is provided in an institution by one of its employees,
	 the entry need not be countersigned unless the institutional provider is
	 responsible for monitoring the provision of such health care. The individual's
	 medical record must include the following additional items as
	 applicable:
(1) Diagnoses,
  assessments, and evaluations;
(2)
  Case history and results of examinations;
(3) Plan of treatment or patient care
  plan;
(4) Quantities and dosages of
  drugs prescribed or administered;
(5) Results of diagnostic tests and
  examinations;
(6) Progress notes
  detailing the recipient's treatment responses, changes in treatment, and
  changes in diagnosis;
(7) A copy of
  any consultation report that is ordered for the recipient;
(8) Dates of hospitalization relating to the
  services provided;
(9) A copy of
  the summary of surgical procedures billed to the medical services
  program;
(10) The date on which the
  entry is made;
(11) The date on
  which the health service is provided; and
(12) The length of time spent with the
  recipient, if the amount paid for services depends on time spent with the
  recipient.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:34 - Records › Section 67:16:34:04 - Required financial records

Current through Register Vol. 51, page 10, July 15, 2024
Providers must maintain an accounting system pursuant to generally
	 accepted accounting practices which enables the provider to clearly identify
	 the cost of services and other expenses of operation. Financial documentation
	 includes the following:
(1) Purchase
  invoices;
(2) Accounting records
  such as payroll ledgers, canceled checks, and bank deposit slips;
(3) Contracts for supplies and services which
  relate to the provider's costs and charges for health care billed to the
  department;
(4) Evidence of the
  provider's usual and customary charge; and
(5) Evidence of claims, payments, or
  settlements made to other third-party health care payers.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Accounting principles, §
		20:37:11:08.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:34 - Records › Section 67:16:34:05 - Record retention

Current through Register Vol. 51, page 10, July 15, 2024
Medical and financial records must be retained for at least six years
	 after the last claim is paid or denied. Records may not be destroyed when an
	 audit or investigation is pending. Medical and financial records must be
	 retained in their original form or in a legally reproduced form, which may be
	 electronic. Providers must have a medical record system that ensures that the
	 record may be accessed and retrieved promptly.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:34 - Records › Section 67:16:34:06 - Record retention - Change of ownership

Current through Register Vol. 51, page 10, July 15, 2024
If there is a change of ownership of a provider entity, facility, or
	 practice, the seller is responsible for maintaining and ensuring access to
	 records generated prior to the sale. The seller may, by way of a sales contract
	 or a written agreement, transfer this responsibility to the
	 buyer.
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 67:16:34 - Records › Section 67:16:34:07 - Record retention - Provider withdrawal or termination

Current through Register Vol. 51, page 10, July 15, 2024
If a provider withdraws or is terminated from the medical services
	 program, records developed during program participation must be retained
	 according to §
									67:16:34:05.
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 67:16:34 - Records › Section 67:16:34:08 - Access to records

Current through Register Vol. 51, page 10, July 15, 2024
Providers must grant the department, the Office of the Attorney
	 General, the Department of Health, the Department of Human Services, and the
	 U.S. Department of Health and Human Services access during regular business
	 hours to examine medical and fiscal records related to health care billed under
	 this article. The investigating agency may photocopy or otherwise duplicate any
	 financial records and any recipient medical records. Photocopying is limited to
	 the provider's premises unless removal is specifically permitted by the
	 provider or the court.
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 67:16:34 - Records › Section 67:16:34:09 - Application of chapter

Current through Register Vol. 51, page 10, July 15, 2024
The rules in this chapter apply to all enrolled providers for services
	 provided to medical assistance program recipients.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:35 - Claims › Section 67:16:35:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Adjustment/void claim form," a form that
  is used to adjust or void a previously paid claim;
(2) "Cross-over claim form," a form used to
  record the Medicare co-insurance and deductible payments for recipients who are
  eligible for both Medicare and Medicaid;
(3) "Denied claim," a claim that does not
  qualify for a medical assistance payment;
(4) "Pended claim," a claim which has not
  been paid or denied but is being reviewed for final action; and
(5) "Remittance advice," a document sent to
  the provider which contains the status of claims submitted by that
  provider.
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 67:16:35 - Claims › Section 67:16:35:02 - Verification of eligibility before claim submitted

Current through Register Vol. 51, page 10, July 15, 2024
Before a provider submits a claim, the provider must verify an
	 individual's eligibility for the medical assistance program by requesting the
	 individual to produce either the individual's medical assistance identification
	 card or a letter from the department which verifies the individual's
	 eligibility. The provider must verify and record the recipient identification
	 as required for 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 67:16:35 - Claims › Section 67:16:35:03 - Claims limited to items and services covered under article

Current through Register Vol. 51, page 10, July 15, 2024
A provider may only submit claims for those supplies and services
	 provided which the provider knows, or should have known, are covered under the
	 provisions of this article. A provider other than a school district, may not
	 submit claims for services provided to children under 21 years of age which the
	 provider knows or should have known are listed in the child's individual
	 education plan.
The submission of a claim containing miscoding that may result in
	 inflated reimbursement or in reimbursement for noncovered services under this
	 article is considered abuse of the program and possible fraud and may be cause
	 for terminating the provider agreement.
General Authority:
SDCL
		28-6-1(1)(2).
Law Implemented:
SDCL
		28-6-1.
School districts, ch 67:16:37.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:35 - Claims › Section 67:16:35:04 - Time limits for submission of claims

Current through Register Vol. 51, page 10, July 15, 2024
The department must receive a provider's completed claim form within
	 six months following the month the service was provided. This time limit may be
	 waived or extended only if one or more of the following situations
	 exist:
(1) The claim is an adjustment
  or void of a previously paid claim and is received within three months after
  the previously paid claim;
(2) The
  claim is received within six months after a retroactive initial eligibility
  determination was made as a result of an appeal;
(3) The claim is received within three months
  after a previously denied claim;
(4) The claim is received within six months
  after the provider receives payment from Medicare or private health insurance
  or receives a notice of denial from Medicare or private health insurance;
  or
(5) To correct an error made by
  the department.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:35 - Claims › Section 67:16:35:05 - Electronic media provider agreement

Current through Register Vol. 51, page 10, July 15, 2024
Providers submitting claims by electronic media must have a signed
	 electronic media agreement with the department before submitting
	 claims.
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 67:16:35 - Claims › Section 67:16:35:06 - Medical assistance cross-over claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A cross-over claim may be submitted to the department if the
	 provider's claim to Medicare did not trigger an automatic payment of the
	 deductible or coinsurance. Proof of payment by Medicare must be attached. A
	 cross-over claim must contain the following information:
(1) The provider's name and National Provider
  Identification (NPI) number and taxonomy code;
(2) The recipient's full name and medical
  assistance identification number from the recipient's medical assistance
  identification card;
(3)
  Third-party liability information required under chapter 67:16:26;
(4) The date of service;
(5) The place of service;
(6) The provider's usual and customary charge
  billed to Medicare;
(7) Units of
  service furnished, if more than one;
(8) The applicable procedure code from the
Health Care Common Procedure Coding System
(HCPCS), as adopted in
  §
									67:16:01:27, or the
Current
  Procedural Terminology
(CPT), as adopted in §
									67:16:01:25;
(9) The amount paid by Medicare plus the
  Medicare discount or write off amount;
(10) Proof of the deductible or co-insurance,
  which must be attached;
(11) The
  amount paid by third-party payers other than Medicare, if any;
(12) The amount originally billed to
  Medicare; and
(13) The type of
  Medicare coverage.
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 67:16:35 - Claims › Section 67:16:35:07 - Adjustment/void claims

Current through Register Vol. 51, page 10, July 15, 2024
A provider may have a previously paid claim adjusted or voided by
	 completing and submitting an adjustment/void claim form to the department. The
	 adjustment/void claim form is available from the department.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:35 - Claims › Section 67:16:35:08 - Requests for reimbursement - Certification

Current through Register Vol. 51, page 10, July 15, 2024
The provider or the provider's representative must sign the claim as a
	 certification of the truth and accuracy of the claim. The provider's name, not
	 the name of the facility or business, must be signed using handwriting,
	 typewriter, signature stamp, computer impulse, or other means utilized as a
	 signature. Each claim must indicate the date the form was
	 signed.
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 67:16:35 - Claims › Section 67:16:35:09 - Use of rubber stamps for claim information

Current through Register Vol. 51, page 10, July 15, 2024
The use of rubber stamps containing claim information is acceptable
	 only if the imprint is legible.
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 67:16:35 - Claims › Section 67:16:35:10 - Claim substantiation

Current through Register Vol. 51, page 10, July 15, 2024
At the department's request, a provider must furnish information needed
	 to substantiate a claim being processed, a claim being reviewed for
	 determination of payment, or a claim under postpayment
	 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 67:16:35 - Claims › Section 67:16:35:12 - Pended claims

Current through Register Vol. 51, page 10, July 15, 2024
The department may pend a claim for any of the following general
	 classes of reasons:
(1) The claim was
  submitted with erroneous, incomplete, or missing information;
(2) The information on the claim does not
  match the state master recipient or provider eligibility files;
(3) The claim requires action by the
  department for medical review, manual pricing, individual requests, late
  submission exceptions, or utilization review;
(4) The department erroneously entered the
  claim into the data processing system;
(5) A third-party source exists;
(6) The claim is a possible duplicate of
  another paid claim;
(7) The claim
  is suspected of being false;
(8)
  The claim is incorrect;
(9) The
  claim is submitted by a provider who is currently being investigated by the
  Medicaid fraud unit; or
(10) The
  claim is submitted by a provider who is currently being reviewed or
  investigated by the department.
Claims pended under subdivision (9) or (10) of this section remain
	 pended until the investigation or review is completed. Time limits for
	 processing claims do not apply to claims pended under subdivision (9) or (10)
	 of this section.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Remittance advice, §
											67:16:35:14;
Timely processing of claims -- Time limitation does not apply to
		claims from providers under investigation for fraud or abuse, 45 C.F.R. §
		447.45 (d)(4)(iii) ;
Payments and obligations to be authorized by law -- Liability to
		state for unauthorized payments, SDCL
		4-8-2.