South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this article mean:
(1) "Allowable costs," those expenses
  incurred in meeting state licensure or federal certification standards for the
  provision of medical services;
(2)
  "Applicant," an individual who has filed an application for participation in
  the medical assistance program;
(3)
  "Claim form" or "claim," a communication used by providers to request payment
  for goods or services reimbursable under this article;
(4) "Centers for Medicare and Medicaid
  Services" or "CMS," the federal agency that administers the Medicare program
  and monitors the Medicaid programs offered by each state;
(5) "Cost sharing," money paid by a recipient
  to a provider for each covered service or procedure rendered to the recipient
  or in the recipient's behalf;
(6)
  "Department," the Department of Social Services;
(7) "Disability/incapacity consultation
  team," a three-member team consisting of a registered nurse and a social worker
  from the department and a consultant physician;
(8) "Emergency," a condition that if not
  immediately diagnosed and treated could cause a person serious physical or
  mental disability, continuation of severe pain, or death;
(9) "Medicaid," the program authorized by
  Title XIX of the Social Security Act,
  42 U.S.C. §
										1396d, as amended to July 1, 2017, which
  covers the allowable medical expenses of eligible individuals;
(10) "Medical assistance" or "medical
  assistance program," the Medicaid program authorized by Title XIX of the Social
  Security Act, 42 U.S.C.
  §
										1396d, as amended to July 1, 2017, and
  SDCL 28-6, which provides medical assistance to eligible individuals;
  assistance provided to children who qualify for the non-Medicaid children's
  health insurance program covered under the provisions of chapter
  67:46:14;
(11) "Other licensed
  practitioner" a physician assistant, nurse practitioner, clinical nurse
  specialist, nurse midwife, or nurse anesthetist who is licensed by the state to
  provide services and is performing within their scope of practice under the
  provisions of SDCL title 36;
(12)
  "Prior authorization," the written approval and issuance of an authorization by
  the department to a provider before certain covered services may be
  provided;
(13) "Reasonable costs,"
  that portion of allowable costs that will be paid for a given medical
  service;
(14) "Recipient," a person
  who is determined by the department to be eligible for services under this
  article;
(15) "SSI," supplemental
  security income;
(16) "Usual,
  customary charge" or "usual and customary," the individual provider's normal
  charge to the general public for a specific service on the day the service was
  provided within the range of charges made by similar providers for such
  services and consistent with the prevailing market rates in the geographic area
  for comparable services; and
(17)
  "Website," the webpage on the department's website that contains specific
  information referred to in this chapter. The following websites are used in
  this chapter.
Billing Guidance Website:
http://dss.sd.gov/medicaid/providers/billingmanuals/
Cost Sharing Website:
http://dss.sd.gov/medicaid/recipients/costsharing.aspx
Fee Schedule Website:
http://dss.sd.gov/medicaid/providers/feeschedules/dss/
Modifier Website:
http://dss.sd.gov/medicaid/modifiers.aspx
Pharmacy Website:
http://dss.sd.gov/medicaid/providers/programinfo/pharmacy/
Prior Authorization Website:
	 http://dss.sd.gov/medcaid/providers/pa/
General Authority:
SDCL 28-6-1,
		42 U.S.C. §
												1396d.
Law Implemented:
SDCL 28-6-1(1)(2)(4)(6),
		42 U.S.C. §
												1396d.