reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:05 - Home health services › Section 67:16:05:05.03 - Supervisory visit required when home health aide services provided

Current through Register Vol. 51, page 10, July 15, 2024
Supervisory visits when home health aide services are being provided
	 must follow the criteria established in
	 42 C.F.R. §
										484.80(h) (June 19,
	 2020).
Supervisory visits are considered to be an overhead cost and may not be
	 billed as a home health service.
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 67:16:05 - Home health services › Section 67:16:05:05.05 - Respiratory therapy - Limitations

Current through Register Vol. 51, page 10, July 15, 2024
An individual receiving home respiratory therapy must meet the
	 following requirements:
(1) Be
  medically dependent on a ventilator for life support at least six hours a day
  and have been dependent for at least 30 consecutive days;
(2) Except for the availability of these
  respiratory care services at home, would require respiratory care as an
  inpatient in a hospital, a skilled nursing facility, or an intermediate care
  facility and would be eligible for long-term nursing care under this
  article;
(3) Have adequate support
  services to be cared for at home; and
(4) Wish to be cared for at home.
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 67:16:05 - Home health services › Section 67:16:05:05.06 - Postpartum services - Limitations

Current through Register Vol. 51, page 10, July 15, 2024
Postpartum services are limited to one visit each day, may not be
	 provided for more than four consecutive weeks following the child's birth, and
	 are subject to the provisions of this chapter. The home health agency must
	 receive approval from the department before providing additional visits. One of
	 the following risk factors must be present and must be documented in the
	 physician or other licensed practitioner's written orders and the home health
	 agency's plan of care:
(1) The mother
  has a documented prenatal or postpartum medical condition which threatens the
  mother's health or the health of the baby;
(2) The infant has a documented medical
  condition which requires skilled nursing intervention;
(3) There is documentation to support a
  finding that the family is at risk for child abuse or neglect;
(4) The family has previously experienced
  neonatal death, stillbirth, or sudden infant death syndrome;
(5) There is a documented history of alcohol
  or drug abuse in the family; or
(6)
  There is a documented history of noncompliance with medical treatment regimens,
  including prenatal care.
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 67:16:05 - Home health services › Section 67:16:05:06 - Services not covered

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the other services not specifically listed in §
									67:16:05:05, the following
	 services are not covered under this chapter:
(1) Physician or other licensed
  practitioner's medical or surgical services;
(2) Drugs and biologicals;
(3) Personal comfort items;
(4) General housekeeping services;
(5) Meals or other nutritional items
  delivered to the individual's home;
(6) Posthospital benefits which include
  services by a home health agency operating primarily for the treatment of
  mental illness;
(7) Visits by a
  dietician;
(8) Visits solely for
  the purpose of teaching the individual or the individual's caregiver;
(9) Services that are not medically
  necessary;
(10) Custodial care;
  and
(11) Mileage.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Covered services -- Limits, §
											67:16:05:05.
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 67:16:05 - Home health services › Section 67:16:05:06.01 - Medical records

Current through Register Vol. 51, page 10, July 15, 2024
A home health agency must maintain a medical record for each individual
	 receiving services. The medical record must contain documentation verifying
	 that the claimed service was performed and was authorized by the attending
	 physician or other licensed practitioner. The individual's medical record must
	 be made available on request to the department, the Medicaid fraud control unit
	 of the Attorney General's Office, or representatives of the United States
	 Department of Health and Human Services. Medical records must be retained for
	 six years.
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 67:16:05 - Home health services › Section 67:16:05:07 - Covered services - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
Covered home health services are limited to the procedures listed on
	 the department's fee schedule website. Payment is limited to the home health
	 agency's usual and customary charge or the rate of payment specified on the
	 department's website, whichever is lower.
A procedure code billed with a modifier of "22" is reimbursed at 125
	 percent of the established rate.
The rates of payment are subject to review and amendment by the
	 department. A provider may request that the department review a particular
	 reimbursement rate for possible adjustment or request the inclusion or
	 exclusion of a particular code from the list. When reviewing the requests, the
	 department shall review paid claims information, Medicare fee schedules,
	 national coding lists, and documentation submitted by the provider or the
	 associated medical professional organization to determine whether a change is
	 warranted.
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 67:16:05 - Home health services › Section 67:16:05:07.01 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim submitted for services provided under this chapter must be
	 submitted at the provider's usual and customary charge and must contain the
	 applicable procedure codes contained on the department's website for covered
	 home health services.
If a registered nurse or a licensed practical nurse performs a home
	 health aide service, the service must be billed as a home health aide
	 service.
If two or more persons of the same discipline simultaneously provide a
	 single service, it is counted as one service and must be billed as a single
	 service.
Skilled nursing or aide visits requiring additional staff to provide
	 the care which is an integral part of one visit must be billed with a modifier
	 "22". The medical record must contain documentation verifying that the claimed
	 service was authorized by the attending physician or other licensed
	 practitioner and was actually provided.
When billing services under this chapter, the provider must include the
	 number of 15-minute units of time spent delivering the needed service.
Except for an electronic claim, if the individual is covered by
	 Medicare or private health insurance, a copy of the denial or evidence of
	 payment from Medicare or the insurance carrier must accompany the claim. For an
	 electronic claim, the provider shall maintain and submit to the department on
	 request evidence of claim payments or rejection.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Third-party liability, ch
		67:16:26.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:05 - Home health services › Section 67:16:05:07.02 - Cost not to exceed institutional care

Current through Register Vol. 51, page 10, July 15, 2024
If the actual or projected cost of all home health services 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 home health agency and to the
	 individual. If within 30 days after the notice the home health agency provides
	 documentation that the future home health service costs 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 67:16:05 - Home health services › Section 67:16:05:07.03 - Services provided outside South Dakota

Current through Register Vol. 51, page 10, July 15, 2024
Services provided outside South Dakota shall be covered if all of the
	 following criteria are met:
(1) The
  services provided are covered under this chapter;
(2) The home health agency has signed a
  provider agreement with the department; and
(3) The home health agency is a participating
  provider in the Medicaid program in the state in which the services are
  provided.
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 67:16:05 - Home health services › Section 67:16:05:08 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Home health services may be reviewed on the following levels:
(1) Computerized claims processing;
(2) Cost comparison to institutional care;
  and
(3) 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 67:16:05 - Home health services › Section 67:16:05:09 - 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 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
  procedure codes for services covered under §
									67:16:05:07;
(8) The applicable diagnosis codes adopted in
  §
									67:16:01:26;
(9) The units of service furnished, if more
  than one; and
(10) The provider's
  name and National Provider Identification (NPI) 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.
Claims, ch 67:16:35.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:05 - Home health services › Section 67:16:05:10 - 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 67:16:06 - Dental services › Section 67:16:06:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Contractor," a vendor that has a
  contract with the department to adjudicate claims for dental services and goods
  provided to eligible recipients of the medical assistance program;
  and
(2) "Dentist," a dentist as
  defined in SDCL
  36-6A-1, a dentist who practices
  one of the specialties listed in §
									20:43:04:01, or an individual
  licensed as a dentist under the laws of another state.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:06 - Dental services › Section 67:16:06:03.01 - Contractor to provide certain services

Current through Register Vol. 51, page 10, July 15, 2024
A contractor must provide the following services:
(1) At a minimum, the dental services
  contained in this chapter;
(2) An
  automated claims processing and payment system capable of providing data on the
  claims encountered;
(3) A provider
  support unit which, at a minimum, provides eligibility information, responds to
  claim inquiries, and responds to questions about covered benefits;
(4) A toll-free telephone service for
  recipients to register complaints, identify problems, and inquire about
  benefits;
(5) A system of provider
  recruitment and retention;
(6) A
  quality assurance program which provides for pre- and post-treatment reviews;
  and
(7) A grievance process for
  providers and recipients. The provider or recipient must exhaust this process
  before requesting a fair hearing 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 67:16:06 - Dental services › Section 67:16:06:04 - Covered services - Limits - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
Covered dental services include, at a minimum, those procedures and
	 limitations contained on the department's fee schedule website.
The rate of payment is limited to the lesser of the provider's usual
	 and customary fee 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.
The covered items and services provided under this chapter for
	 children under the age of 21 are not subject to the established limits.
Coverage for nonemergency adult dental services is limited to $ 2,000
	 per state fiscal year.
General Authority:
SDCL
		28-6-1(1)(2).
Law Implemented:
SDCL
		28-6-1,
		28-6-1.1.
Eligibility requirements, §
											67:46:01:02.
Qualified Medicare Beneficiaries (QMB), ch 67:46:11.
Fee Schulte Website Definition, §
											67:16:01:01(18).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:06 - Dental services › Section 67:16:06:07

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 67:16:06 - Dental services › Section 67:16:06:08 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
A provider submitting a claim under this chapter must submit the claim
	 to the contractor.
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 67:16:06 - Dental services › Section 67:16:06:10 - 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 and
	 67:16:26.
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 67:16:07 - Podiatric services › Section 67:16:07:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Flatfoot," a condition in which one or
  more arches in the foot have flattened out;
(2) "Podiatrist," an individual who meets the
  licensure and certification requirements of SDCL
  36-8-6 and who performs the acts
  allowable under SDCL
  36-8-1; and
(3) "Subluxations of the foot," partial
  dislocations or displacements of joint surfaces, tendons, ligaments, or muscles
  of the foot.
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 67:16:07 - Podiatric services › Section 67:16:07:03 - Covered services - Limits

Current through Register Vol. 51, page 10, July 15, 2024
Podiatry services covered are limited to those surgical and
	 nonsurgical podiatry procedures listed on the department's fee schedule
	 website, unless excluded by §
									67:16:07:04.
Podiatry services provided to a resident of a long-term care facility
	 must be the result of a self-referral, a referral by a nurse who is employed by
	 the facility, or a referral by the recipient's family, guardian, physician, or
	 other licensed practitioner.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2),
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:07 - Podiatric services › Section 67:16:07:04 - Services not covered

Current through Register Vol. 51, page 10, July 15, 2024
The following podiatry services are not covered under the medical
	 assistance program:
(1) Stock
  orthopedic shoes, unless covered under chapter 67:16:11 for children less than
  twenty-one years of age, or built into a leg brace;
(2) The treatment of flatfoot;
(3) Surgical or nonsurgical treatment of
  subluxations of the foot, undertaken for the sole purpose of correcting a
  subluxated structure in the foot as an isolated entity, but not including:
(a) Surgical correction of a subluxated foot
  structure that is an integral part of the treatment of a foot injury;
  or
(b) Surgical correction of a
  subluxated foot structure that is undertaken to improve the function of the
  foot or to alleviate an inducted or associated symptomatic condition;
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:07 - Podiatric services › Section 67:16:07:05 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
A claim submitted under this chapter must be submitted at the
	 podiatrist's usual and customary charge. Except for bilateral or multiple
	 surgeries, payment is limited to the lesser of the provider's usual and
	 customary charge or the fee contained on the department's website. If no fee is
	 listed, payment is limited to 40 percent of the provider's usual and customary
	 charge. The maximum rate of payment for covered podiatry services is available
	 on the department's fee schedule website.
If a provider performs bilateral or multiple surgeries during the same
	 operating session, the department follows the payment methodology established
	 in chapter 67:16:02.
A provider may request that the rate of payment be amended. The
	 request must be in writing and directed to the department's state Medicaid
	 director. The provider must specify the reason for the requested change. The
	 department shall review the request and determine whether the rate change is
	 warranted and there is sufficient revenue to cover the increase. When the
	 department takes final action on the requested change, the department shall
	 notify the podiatrist who requested the change. A change in a payment rate is
	 reflected on the department's fee schedule website.
General Authority:
SDCL
		28-6-1(1)(2).
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 67:16:07 - Podiatric services › Section 67:16:07:05.01

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 67:16:07 - Podiatric services › Section 67:16:07:06 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for podiatry 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 67:16:07 - Podiatric services › Section 67:16:07:07 - 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 applicable procedure
	 codes for the podiatry services provided.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Third-party liability, ch 67:16:26.
Covered services -- Limits, §
											67:16:07:03.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:07 - Podiatric services › Section 67:16:07:08 - 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
  procedure codes for services covered under the provisions of §
									67:16:07:03;
(8) The applicable diagnosis codes adopted in
  §
									67:16:01:26;
(9) The units of service furnished, if more
  than one; and
(10) The provider's
  name and National Provider Identification (NPI) 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.
Claims, ch 67:16:35.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:07 - Podiatric services › Section 67:16:07:09 - Application of other chapters

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the rules contained in this chapter, providers and
	 recipients must meet the requirements of 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 67:16:08 - Optometric and optical services › Section 67:16:08:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Amblyopia," the condition that exists
  when there is reduced vision in an eye because it did not receive adequately
  focused retinal stimulus during early childhood;
(2) "Anisometropia," the difference in the
  refractive power of the two eyes;
(3) "Aphakia," the absence of an eye's
  lens;
(4) "Diopter," the unit of
  refractive power of lenses;
(5)
  "Irregular astigmatism," the condition in which the curvature in different
  parts of the same meridian of the eye varies or in which successive meridians
  differ irregularly in refraction;
(6) "Myopia," that error of refraction in
  which rays of light entering the eye parallel to the optic axis are brought to
  focus in front of the retina;
(7)
  "Optician," a supplier of eyeglasses as prescribed by an optometrist;
(8) "Optometric and optical care services,"
  prescriptive, diagnostic, dispensing, or therapeutic services provided by an
  optometrist, optician, or optical company;
(9) "Optometrist," an individual who
  practices optometry as defined in SDCL
  36-7-1 or an individual licensed
  to practice optometry under the laws of another state; and
(10) "Therapeutic," healing,
  curative.
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 67:16:08 - Optometric and optical services › Section 67:16:08:04 - Covered services - Limits

Current through Register Vol. 51, page 10, July 15, 2024
Optometric and optical services are subject to the limits established
	 in this chapter. Covered services are limited to the services and supplies
	 listed on the department's fee schedule website. The covered services and
	 supplies are subject to the following limits:
(1) Initial contact lenses if necessary for
  the correction of irregular astigmatism, anisometropia in excess of four
  diopters, or refractive error in excess of six diopters in one meridian of
  either eye;
(2) Replacement contact
  lenses for standard rigid gas permeable or standard annual replacement, daily
  wear soft contact lenses are limited to two lenses a year which may consist of
  two lenses for one eye or one lens for each eye. Recipients fitted with planned
  replacement daily wear soft contact lenses must be provided with a year's
  supply of lenses at the initial fitting and no other replacement lenses may be
  covered during that year;
(3)
  Contact lenses for therapeutic use;
(4) Permanent prosthesis (eyeglasses) for
  aphakia;
(5) Replacement eyeglasses
  if a minimum of 15 months has passed since the present eyeglasses were received
  and a lens change is medically necessary, if new eyeglasses are required
  because of a change in correction of at least .5 diopters, or if the eyeglasses
  are broken beyond repair and the broken eyeglasses are returned to the
  provider;
(6) Polycarbonate lens
  only if the recipient has a prosthetic eye, monocular vision, or the
  recipient's corrected visual acuity is 20/50 or less in one eye because of
  amblyopia or injury; and
(7) High
  index lenses if the recipient has at least plus or minus 7.00 diopters in the
  meridian of greatest power when placed on an optical cross.
The covered items and services provided under this chapter for children
	 under the age of 21 are not subject to the limits contained in this section if
	 the items or services are medically necessary.
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 67:16:08 - Optometric and optical services › Section 67:16:08:05 - Services not covered

Current through Register Vol. 51, page 10, July 15, 2024
The department does not cover the following items or services and, if
	 provided, reimbursement must be obtained from the recipient:
(1) Extended wear or daily disposable contact
  lenses;
(2) Regular eyeglasses or
  contact lenses when used to supplement another pair of corrective vision
  lenses;
(3) Athletic
  glasses;
(4) Tinting, additional
  charges for photochromic lenses, lens decoration, or special lens
  coating;
(5) Frames if a lens
  change is not medically necessary;
(6) LASIK surgery; and
(7) Consultation services.
The provisions of this rule are not applicable to the items or services
	 provided for children under the age of 21 if documented as medically
	 necessary.
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 67:16:08 - Optometric and optical services › Section 67:16:08:06 - Rate of payment

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. Payment is limited to the lesser of the
	 provider's usual and customary charge or the amount specified on the
	 department's fee schedule website.
The rates of payment are subject to review and amendment by the
	 department. A provider may request that the department review a particular
	 reimbursement rate for possible adjustment or request the inclusion or
	 exclusion of a particular code from the list. When reviewing the requests, the
	 department shall review paid claims information, Medicare fee schedules,
	 national coding lists, and documentation submitted by the provider or the
	 associated medical professional organization to determine whether a change is
	 warranted.
General Authority:
SDCL
		28-6-1(2),
		28-6-1.1.
Law Implemented:
SDCL
		28-6-1(2),
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:08 - Optometric and optical services › Section 67:16:08:06.01 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
Claims must be submitted at the provider's usual and customary charge
	 and must contain the applicable procedure codes for the covered services
	 provided.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Third-party liability, ch 67:16:26.
Covered services -- Limits, §
											67:16:08:04.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:08 - Optometric and optical services › Section 67:16:08:07 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for optometric and optical services may be conducted
	 on the following levels:
(1)
  Computerized claims processing;
(2)
  Postpayment review; and
(3) Peer
  review.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:08 - Optometric and optical services › Section 67:16:08:08

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 67:16:08 - Optometric and optical services › Section 67:16:08:09 - 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 or in an electronic format that contains the following information:
(1) The recipient's full name;
(2) The recipient's medical assistance 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 must not subtract other third-party or cost-sharing
  payments from this charge;
(7) The
  applicable procedure codes for the covered services provided;
(8) The units of service furnished, if more
  than one; and
(9) The provider's
  name and national provider identification 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.
Claims, ch 67:16:35.
Covered services, §
											67:16:08:04.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:08 - Optometric and optical services › Section 67:16:08:10 - 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 67:16:09 - Chiropractic services › Section 67:16:09:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Chiropractic services," those diagnostic
  and treatment services provided by a chiropractor to detect and treat one or
  more subluxations of the spine;
(2)
  "Chiropractor," a person licensed by the board of chiropractic examiners; a
  person who is licensed as a chiropractor in another state;
(3) "Manual manipulation," a method used to
  successfully relocate a subluxated vertebra which consists of an assisted
  motion applied to the vertebra beyond the active and passive range of motion;
  and
(4) "Subluxation," an
  incomplete or partial dislocation.
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 67:16:09 - Chiropractic services › Section 67:16:09:03 - Covered services

Current through Register Vol. 51, page 10, July 15, 2024
Covered chiropractic services are limited to the procedures listed on
	 the department's fee schedule website.
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 67:16:09 - Chiropractic services › Section 67:16:09:05 - 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 must contain the applicable procedure
	 codes for the chiropractic services provided.
A provider may not bill multiple units of procedure code 72020 if a
	 multiple-view procedure code is applicable. The number of units indicates the
	 number of times a procedure is performed, not the number of views.
A provider may not submit a claim for procedure code 99211 in
	 conjunction with procedure code 99201. A provider may not submit a claim for
	 procedure code 99211 more than once in any 12 month period. Annual claims for
	 procedure code 99211 must show continued medical necessity and progress towards
	 improvement of the condition, negating the possibility of maintenance therapy.
	 An additional claim for procedure code 99211 may be submitted within the 12
	 month period for a separate and distinct injury with supporting documentation
	 of medical necessity. A provider may not submit a claim for procedure code
	 99201 or 99211 unless it is the provider's custom to charge the general public
	 for these services.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Third-party liability, ch 67:16:26.
Covered services -- Limits, §
											67:16:07:03.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:09 - Chiropractic services › Section 67:16:09:05.01 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment for chiropractic 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.
Manual manipulation of the spine is limited to one treatment a day and
	 30 treatments in each 12 month period, in any combination of the codes 98940,
	 98941, or 98942.
The rates of payment are subject to review and amendment by the
	 department. A provider may request that the department review a particular
	 reimbursement rate for possible adjustment or request the inclusion or
	 exclusion of a particular code from the list. When reviewing the requests, the
	 department shall review paid claims information, Medicare fee schedules,
	 national coding lists, and documentation submitted by the provider or the
	 associated medical professional organization to determine whether a change is
	 warranted.
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 67:16:09 - Chiropractic services › Section 67:16:09:06 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review of services covered under this chapter may be
	 conducted on any of the following three levels:
(1) Computerized claims processing;
(2) Postpayment review; and
(3) Peer reviews.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
42 U.S.C. §
												1396
		(a)(33)(A).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:09 - Chiropractic services › Section 67:16:09:07

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 67:16:09 - Chiropractic services › Section 67:16:09:08 - 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 for services provided;
(8) The applicable diagnosis codes, limited
  to codes to detect and treat one or more subluxations of the spine, adopted in
  §
									67:16:01:26;
(9) The units of service furnished, if more
  than one; and
(10) The provider's
  name and National Provider Identification (NPI) number.
A separate 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.
Claims, ch 67:16:35.
Covered services, §
											67:16:09:03.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:09 - Chiropractic services › Section 67:16:09:09 - Application of other chapters

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the rules contained in this chapter, providers and
	 recipients must meet the requirements of 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 › Section 67:16:11:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Early and periodic screening, diagnosis,
  and treatment" or "EPSDT," screening and diagnostic services available to
  eligible individuals under 21 years of age to determine physical or mental
  status and provide health care treatment and other measures to correct or
  ameliorate defects or chronic conditions discovered;
(2) "Extended home health aide services,"
  those nursing-related services not required to be performed by a licensed
  health professional but prescribed by a licensed physician;
(3) "Plan of care," the written plan
  developed by a licensed nurse in response to the attending physician's written
  order to the nurse prescribing the needed services and the duration of those
  services;
(4) "Private duty
  nursing," nursing services as defined in SDCL
  36-9-3 for technology-dependent
  individuals who require more than three consecutive hours of patient care than
  is available from a visiting nurse or routinely provided by the nursing staff
  of a hospital or nursing facility;
(5) "Psychologist," for services provided in
  South Dakota, a person licensed under SDCL
  36-27A-12 or
  36-27A-13; for services provided
  in another state, a person licensed as a psychologist in the state where the
  services are provided. For purposes of the medical assistance program, a person
  practicing under SDCL
  36-27A-11 is specifically
  excluded;
(6) "Screening," the use
  of examination procedures to determine the existence of certain physical or
  mental illnesses or conditions; and
(7) "Technology-dependent individual," an
  individual who relies on life-sustaining medical technology to compensate for
  the loss of a vital body function and requires ongoing, complex, hospital-level
  nursing care to avert death or further disability.
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 67:16:11:02 - Eligibility requirements

Current through Register Vol. 51, page 10, July 15, 2024
Except for qualified Medicare beneficiaries eligible under chapter
	 67:16:30, an individual is eligible for assistance under the EPSDT program if
	 the individual is under 21 years of age and otherwise eligible for medical
	 assistance under this article.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL 28-6-1,
		42 U.S.C. §
												1396
		d.
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 - Covered services - Limits

Current through Register Vol. 51, page 10, July 15, 2024
EPSDT services are limited to the following:
(1) Screening services conducted under the
  provisions of §§
									67:16:11:04 and
  67:16:11:04.01;
(2) Orthodontic services when the
  requirements of § 67:16:11:03.06 have been met;
(3) Private duty nursing services when the
  requirements of §§ 67:16:11:03.20 and 67:16:11:03.22 have been
  met;
(4) Extended home health aide
  services when the requirements of § 67:16:11:03.21 have been
  met;
(5) Nutritional supplements
  when the requirements of § 67:16:11:03.05 have been met; and
(6) Immunizations when the requirements of
  § 67:16:11:05:01 have been met.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL 28-6-1,
		42 U.S.C. §
												1396
		d.
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 67:16:11:03.05 - Nutritional therapy and nutritional supplements

Current through Register Vol. 51, page 10, July 15, 2024
Nutritional therapy and nutritional supplements are covered under the
	 provisions of §§
									67:16:42:02,
	 67:16:42:06, and
	 67:16:42:07.
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 67:16:11:03.06 - Orthodontic treatment

Current through Register Vol. 51, page 10, July 15, 2024
Orthodontic treatment is subject to prior authorization. The
	 authorization is based on the results of an orthodontic evaluation and
	 assessment completed by the treating dentist or orthodontist. In addition, the
	 following requirements must be met:
(1) The treatment is medically necessary to
  correct a handicapping malocclusion;
(2) There are reasonable assurances that the
  teeth are in good condition and will remain in good condition for a
  considerable length of time; and
(3) There is reason to anticipate that the
  recipient will be compliant with scheduled appointments and the treating
  dentist's or orthodontist's treatment plan.
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 67:16:11 - Early and periodic screening › Section 67:16:11:03.08 - Orthodontic treatment - Treatment exceeds $500 - Individual eligible after treatment started - Medical assistance program not original provider - Change in provider. Repealed

Current through Register Vol. 51, page 10, July 15, 2024