reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:04.08 - Secure medical transportation - Provider to maintain certain records

Current through Register Vol. 51, page 10, July 15, 2024
A provider must maintain the following written documents and must make
	 them available to the department on request:
(1) The dates each of the requirements
  contained in §§
									67:16:25:04.01 and
  67:16:25:04.02 were verified by
  the provider;
(2) A statement
  signed and dated by the provider which verifies that each vehicle used for
  secure medical transportation meets the requirements in §
									67:16:25:04.03;
(3) A statement signed and dated by the
  provider which verifies that the securement devices meet the requirements of
  §
									67:16:25:04.04;
(4) A record of the safety inspections
  conducted under §
									67:16:25:04.05. The record must
  contain the date of the inspection, the odometer reading, the result of the
  inspection, and a notation of the repairs needed;
(5) The service records for each vehicle and
  wheelchair lift indicating the date, the odometer reading, and the nature of
  the maintenance work performed;
(6)
  A statement from the insurance carrier that verifies that each vehicle used to
  transport recipients has insurance which meets or exceeds the requirements
  established in § 67:16:25:04.06;
(7) The accident records of each vehicle
  involved in an accident; and
(8) A
  record of complaints received and a statement describing how the provider
  responded to each complaint.
General Authority:
SDCL
		28-6-1(2)(4).
Law Implemented:
SDCL
		28-6-1(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:05 - Rate of payment for secure medical transportation services

Current through Register Vol. 51, page 10, July 15, 2024
The rate of payment for secure medical transportation 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.
Mileage may only be claimed for trips outside the city limits. To be
	 eligible for loaded mileage for trips outside the city limits, the provider
	 must have legal authority to operate outside the city limits.
Payment for secure medical transportation services outside the city
	 limits includes the applicable trip fee as indicated in this section and loaded
	 mileage calculated from the point the trip goes outside the city limits to the
	 destination. Only one mileage allowance is payable for each trip regardless of
	 the number of passengers.
The procedures 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.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:06.01 - Transportation services provided by community transportation provider

Current through Register Vol. 51, page 10, July 15, 2024
Community transportation services are covered if the following
	 requirements are met:
(1) The
  transportation provider is a governmental entity, secure medical transportation
  provider, or registered as a nonprofit organization with the South Dakota
  Secretary of State;
(2) The
  transportation provider is domiciled in the State of South Dakota or enrolled
  as a Medicaid transportation provider in the entity or organization's state of
  domicile;
(3) The entity or
  organization has a signed transportation provider agreement with the department
  to furnish nonemergency medical transportation to recipients;
(4) Transportation is from an eligible
  recipient's residence, bus stop nearest to the recipient's residence, place of
  work, or school to a medical provider, between medical providers, or from a
  medical provider to the recipient's residence, bus stop nearest to the
  recipient's residence, place of work, or school. A recipient's residence does
  not include a hospital, penal institution, detention center, campus setting,
  nursing facility, an intermediate care facility for individuals with
  intellectual disabilities, or an institute for the treatment of an individual
  with a mental disease;
(5)
  Transportation is to or from medically necessary examinations or treatment when
  the services are covered under article 67:16 and are provided by a provider who
  is enrolled or eligible for enrollment in the medical assistance program;
  and
(6) Transportation is to the
  closest facility or medical provider capable of providing the necessary
  services, unless the recipient has a written referral or a written
  authorization from a medical provider in the recipient's medical
  community.
General Authority:
SDCL
		28-6-1(1)(2).
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:06.02 - Reimbursable services - Community transportation provider

Current through Register Vol. 51, page 10, July 15, 2024
If the requirements of §
									67:16:25:06.01 are met,
	 reimbursable community transportation services are limited to the
	 following:
(1) Transport of a
  recipient; and
(2) Mileage.
Transportation expenses payable by a third party are not eligible for
	 reimbursement 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 67:16:25 - Transportation services › Section 67:16:25:06.03

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 67:16:25 - Transportation services › Section 67:16:25:06.04

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 67:16:25 - Transportation services › Section 67:16:25:06.05

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 67:16:25 - Transportation services › Section 67:16:25:06.06

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 67:16:25 - Transportation services › Section 67:16:25:06.07

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 67:16:25 - Transportation services › Section 67:16:25:06.08

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 67:16:25 - Transportation services › Section 67:16:25:07.01 - Rate of payment for community transportation services

Current through Register Vol. 51, page 10, July 15, 2024
The rate of payment for community transportation services is available
	 on the department's fee schedule website.
Reimbursement for loaded mileage is allowed if the trip extends beyond
	 the city limits and the trip is more than 20 miles one way. In this case,
	 payment includes the applicable trip fee as indicated in this section and
	 loaded mileage. Loaded mileage is limited to actual mileage between two cities
	 and does not include in-town driving.
Reimbursement for mileage when a recipient is not being transported is
	 allowed if a trip extends beyond the city limits, is more than 20 miles one
	 way, and the driver is returning to the point of origin after delivering a
	 recipient or is traveling to a medical institution to transport a recipient who
	 is being discharged. In this case, payment is limited to the actual mileage
	 between the two cities and does not include in-town driving.
Only one mileage allowance is payable for each trip regardless of the
	 number of passengers.
The procedures 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(1)(2).
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 67:16:25 - Transportation services › Section 67:16:25:07.02

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 67:16:25 - Transportation services › Section 67:16:25:07.03

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1(1)(2).
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 67:16:25 - Transportation services › Section 67:16:25:07.04

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 67:16:25 - Transportation services › Section 67:16:25:08 - Billing requirements - Ground ambulance

Current through Register Vol. 51, page 10, July 15, 2024
A claim for ground ambulance transportation service must be submitted
	 at the provider's usual and customary charge. A provider may bill for services
	 only if a recipient was actually transported or medically necessary services
	 were provided at the pick-up point. A provider may not bill for any portion of
	 ambulance service during which the recipient was not physically present in the
	 ambulance.
Return trips or other nonemergency trips by ground ambulance must be
	 justified by a physician or other licensed practitioners order. Documentation
	 of the order must exist in the provider's files but need not be submitted with
	 the claim for payment.
A claim for ground ambulance service must contain the procedure codes
	 established in §
									67:16:25:03.
Charges for transporting the patient from the airport to the hospital
	 or from the hospital to the airport must be billed by the ground ambulance
	 provider and may not be included in the air ambulance charge.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
Third-party liability, ch
		67:16:26.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:08.01 - Billing requirements - Secure medical transportation

Current through Register Vol. 51, page 10, July 15, 2024
A claim for secure medical transportation service must be submitted at
	 the provider's usual and customary charge.
A provider may bill for services only if a recipient has been
	 transported. A provider may not bill for any portion of a secure medical
	 transportation service during which the recipient was not physically present in
	 the secure medical transportation vehicle.
A provider may not submit a claim for in-town mileage. If an extra
	 patient was transported with the recipient, the provider must add the modifier
	 "TK" to the procedure code being billed. If a hospital arranged for the
	 transfer, the provider must add the modifier "QM" to the procedure code being
	 billed.
General Authority:
SDCL
		28-6-1
Law Implemented:
SDCL
		28-6-1(1)(2)(4)
Third-party liability, ch
		67:16:26.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:08.03 - Billing requirements - Air ambulance

Current through Register Vol. 51, page 10, July 15, 2024
A claim for air ambulance must be submitted at the provider's usual
	 and customary charge. A provider may bill for services only if a recipient was
	 actually transported. A provider may not bill for any portion of ambulance
	 service during which the recipient was not physically present in the air
	 ambulance.
A claim for emergency air ambulance services must contain the
	 applicable procedure codes for the services provided.
Charges for transporting the patient from the airport to the hospital
	 or from the hospital to the airport must be billed by the ground ambulance
	 provider and may not be included in the air ambulance charge. If an extra
	 patient is transported with the recipient, the provider must add the modifier
	 "TK" to the procedure code being billed.
A copy of the physician or other licensed practitioner's written order
	 specifying the medical necessity and the level of air transportation medically
	 required must be maintained in the provider's records and made available on
	 request.
General Authority:
SDCL
		28-6-1(1)(2)(4)
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 67:16:25 - Transportation services › Section 67:16:25:08.04 - Billing requirements - Community transportation services

Current through Register Vol. 51, page 10, July 15, 2024
A claim submitted for community transportation services must be at the
	 provider's usual and customary charge. A provider may not submit a claim for
	 loaded mileage if the trip is 20 miles or less.
A claim for community transportation services must contain the
	 applicable procedure codes for the services provided. If an extra patient is
	 transported with the recipient, the provider must add the modifier "TK" to the
	 procedure code being billed. If the trip is outside the provider's customary
	 service area, the provider must add the modifier "TN" to the procedure code
	 being billed.
A long-term care facility may not submit a claim for community
	 transportation services. Such services are considered routine under the
	 provisions of §
									67:16:04:41 and are included in
	 the facility's cost reports required in §
									67:16:04:34.
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 67:16:25 - Transportation services › Section 67:16:25:09 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for transportation 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 67:16:25 - Transportation services › Section 67:16:25:10 - Claim requirements - Ambulance

Current through Register Vol. 51, page 10, July 15, 2024
A claim for air or ground ambulance 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 point of origin and the destination
  of the recipient being transported;
(7) The provider's usual and customary
  charge. The provider may not subtract other third-party or cost-sharing
  payments from this charge;
(8) The
  applicable procedure codes for the services provided;
(9) The applicable diagnosis codes adopted in
  §
									67:16:01:26, or the reason the
  recipient required the type of transportation provided;
(10) The units of service furnished, if more
  than one;
(11) The provider's name
  and National Provider Identification (NPI) number; and
(12) The reason for any additional attendant
  provided. 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 67:16:25 - Transportation services › Section 67:16:25:11 - Claim requirements - Secure medical transportation

Current through Register Vol. 51, page 10, July 15, 2024
A claim for secure medical transportation 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 point of origin and the destination
  of the recipient being transported;
(7) The provider's usual and customary
  charge. The provider must not subtract other third-party or cost-sharing
  payments from this charge;
(8) The
  applicable procedure codes for the services provided;
(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(1)(2)(4).
Note:
The CMS 1500 form substantially meets the
		requirements of this rule and its content and appearance are acceptable to the
		department. These forms are available for direct purchase through the
		Superintendent of Documents, U.S. Government Printing Office, Washington, D.C.
		20402. (202) 783-3238 - pricing desk.
Claims, ch 67:16:35.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:12.01 - Claim requirements - Community transportation services

Current through Register Vol. 51, page 10, July 15, 2024
A claim for community transportation 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) Date of service;
(4) The point of origin and the destination
  of the recipient being transported;
(5) The provider's usual and customary
  charge;
(6) The applicable
  procedure codes for the services provided;
(7) The units of service furnished, if more
  than one; and
(8) 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(1)(2)(4).
Note:
The CMS 1500 form substantially meets the
		requirements of this rule and its content and appearance are acceptable to the
		department. These forms are available for direct purchase through the
		Superintendent of Documents, U.S. Government Printing Office, Washington, D.C.
		20402. (202) 783-3238 - pricing desk.
Claims, ch 67:16:35.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:12.02

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 67:16:25 - Transportation services › Section 67:16:25:12.03

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 67:16:25 - Transportation services › Section 67:16:25:12.04

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 67:16:25 - Transportation services › Section 67:16:25:12.05 - Claim requirements - Modifier codes - Ambulance, secure medical, and community transportation services

Current through Register Vol. 51, page 10, July 15, 2024
A modifier code provides the means by which the reporting provider
	 indicates on the claim form that a service that was provided was altered by
	 some specific circumstance but not changed in its definition or code. When
	 applicable, the following codes must be included on a provider's claim for
	 ambulance, secure medical, or community transportation services:
Modifier
Description
TK
Extra patient
TN
Rural/outside the provider's customary service area
QM
Hospital arranged secure medical transfer.
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 67:16:25 - Transportation services › Section 67:16:25:13 - 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 67:16:25 - Transportation services › Section 67:16:25:14 - Recovery of amounts overpaid

Current through Register Vol. 51, page 10, July 15, 2024
The department considers a payment made on behalf of a recipient for
	 non-emergency transportation assistance that exceeds the amount reimbursable
	 under this chapter to be an overpayment and subject to recovery. The department
	 may use a payment due to a provider as an offset against a provider's existing
	 overpayment.
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 67:16:26 - Third-party liability › Section 67:16:26:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Private health insurance," medical or
  hospital insurance coverage with benefits payable to or in behalf of an
  eligible recipient;
(2) "Probable
  existence of third-party liability," an indication in the individual's case
  record which suggests that a possible third-party resource exists which may be
  liable for the individual's medical expenses, or the identification of a
  third-party resource with a reasonable expectation that the third-party
  resource will pay on the claim; and
(3) "Third-party liability" or "third-party
  payment source," the obligation of an entity other than the medical assistance
  program for either partial or full payment of the medical cost of injury,
  disease, or disability. Third-party liability sources include coverage such as
  Medicare, private health insurance, worker's compensation, disability
  insurance, and automobile insurance.
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 67:16:26 - Third-party liability › Section 67:16:26:02 - Responsibility for reporting of third-party liability - Recipients

Current through Register Vol. 51, page 10, July 15, 2024
As a condition of eligibility, a recipient must report to and cooperate
	 with the department in securing information on and payments from third-party
	 liability sources. Information must be reported to the department as soon as
	 the recipient is aware of or has reason to believe that a third-party liability
	 source exists.
Information to be reported includes items such as the name of the
	 policy holder, the policy holder's relationship to the recipient, the policy
	 holder's social security number, the name and address of the insurance company,
	 and the policy number.
Cooperation includes providing the name and address of any legal
	 representative retained by or on behalf of the recipient to pursue litigation
	 for any accident or trauma which resulted in payment by the department for
	 services.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Assignment of rights to benefits,
		42 C.F.R. §
												435.610.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:26 - Third-party liability › Section 67:16:26:03 - Responsibility for reporting of third-party liability - Applicants

Current through Register Vol. 51, page 10, July 15, 2024
As a condition of eligibility, an applicant must provide information
	 about the existence of any third-party payment source. The information includes
	 items such as the name of the policy holder, the policy holder's relationship
	 to the applicant, the policy holder's social security number, the name and
	 address of the insurance company, and the policy number.
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 67:16:26 - Third-party liability › Section 67:16:26:04 - Provider notification of third-party liability

Current through Register Vol. 51, page 10, July 15, 2024
If the department has knowledge that a third-party liability source
	 exists for a particular recipient, the department shall notify providers of
	 such coverage through either the department's medical eligibility verification
	 system or the audio response system.
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 67:16:26 - Third-party liability › Section 67:16:26:05 - Provider must collect from third-party source before submitting claim to department - Medical assistance program payer of last resort - Payment provision

Current through Register Vol. 51, page 10, July 15, 2024
Because the medical assistance program is the payer of last resort, a
	 provider must pursue the availability of third-party payment sources whether or
	 not the sources are identified by the department.
The provider must be able to document the provider's pursuit of the
	 availability of a third-party payment source, except for claims listed in
	 §
									67:16:26:07.02. The documentation
	 must be maintained in the recipient's records. Documentation may include a
	 signed statement by the recipient informing the provider of all third-party
	 payment sources.
Once the provider has identified a third-party payment source, the
	 provider must submit a completed claim for payment of services to the
	 third-party source before requesting payment from the department. Except for an
	 electronic claim, if a claim is subsequently submitted to the department for
	 payment, evidence of third-party payment or rejection must accompany the claim.
	 For an electronic claim, the provider must maintain and submit to the
	 department on request evidence of the third-party payment or rejection. The
	 provider is eligible to receive the recipient's third party liability
	 responsibility amount or the amount allowed under the department's payment
	 schedule less the third-party liability amount, whichever is less.
The department may not pay for any service that has been denied by the
	 third-party liability source as not meeting the requirements for submitting a
	 claim.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Department determination of possible existence of third-party source
		-- Claim denial, §
											67:16:26:07.
Certain claims eligible for payment before third-party benefits
		recovered -- Department to pursue reimbursement, §
											67:16:26:07.02.
Records, ch 67:16:34.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:26 - Third-party liability › Section 67:16:26:07 - Department determination of possible existence of third-party source - Claim denial

Current through Register Vol. 51, page 10, July 15, 2024
When a provider has requested payment of a claim and the department has
	 documentable reason to believe that a possible third-party payment source
	 exists, the department shall deny the claim unless it is covered under the
	 provisions of § 67:16:26:07.02. Claims denied under this section may not
	 be resubmitted until the conditions of §
									67:16:26:05 have been
	 met.
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 67:16:26 - Third-party liability › Section 67:16:26:07.01 - Payment provisions when third-party source involves Medicare

Current through Register Vol. 51, page 10, July 15, 2024
If a recipient is eligible for Medicare, the provider must submit a
	 completed claim for payment of services to the Medicare carrier or
	 intermediary. The provider is eligible to receive payment from the department
	 for the deductible and coinsurance as indicated on the explanation of benefits
	 for those physician and outpatient services allowed by the Medicare carrier.
	 Deductible and coinsurance payments for inpatient hospital services are subject
	 to chapter 67:16:03.
The department may not pay for any service that has been denied by
	 Medicare as not medically necessary or reasonable or as not meeting the
	 requirements for submitting a 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 67:16:26 - Third-party liability › Section 67:16:26:07.02 - Certain claims eligible for payment before third-party benefits recovered - Department to pursue reimbursement

Current through Register Vol. 51, page 10, July 15, 2024
A provider is eligible to receive payment for the full amount allowed
	 under the department's payment schedule while the department pursues
	 reimbursement from third-party sources in the following situations:
(1) The claim is for services for early and
  periodic screening, diagnosis, and treatment, provided under chapter 67:16:11,
  except for psychiatric inpatient services, nutritional therapy, nutritional
  supplements, and electrolyte replacements;
(2) The third-party liability is derived from
  an absent parent whose obligation to pay support is being enforced by the
  department and 100 days from the date of service have elapsed;
(3) The probable existence of third-party
  liability cannot be established at the time the claim is filed;
(4) The claim is for nursing facility
  services reimbursed under chapter 67:16:04; or
(5) The claim is for services provided by a
  school district under chapter 67:16:37.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1(2)(4).
Pay and chase provisions,
		42 C.F.R. §
												433.139.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:26 - Third-party liability › Section 67:16:26:07.03 - Provider may not pursue payment from recipient when third-party liability established

Current through Register Vol. 51, page 10, July 15, 2024
When third-party liability has been established and the amount of the
	 third-party liability equals or exceeds the amount payable under the medical
	 services program, the provider may not seek to collect any payment amount for
	 that service from the recipient, any financially responsible relative, or any
	 legal representative. The provider must pursue collection from the third-party
	 payment source.
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 67:16:26 - Third-party liability › Section 67:16:26:08 - Reimbursement from third-party collections

Current through Register Vol. 51, page 10, July 15, 2024
If the department has made payments in behalf of a recipient, providers
	 and recipients must reimburse the department when a payment is received from a
	 third-party liability source. The total reimbursement must be either the amount
	 of the third-party payment for services paid by the department or the amount
	 paid by the department, whichever is less.
If a recipient employs an attorney to establish a third-party liability
	 source and the attorney collects from that source, the department may
	 participate in the payment of the attorney's fees and expenses by reducing the
	 amount of the reimbursement due 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 67:16:26 - Third-party liability › Section 67:16:26:09 - Claims review

Current through Register Vol. 51, page 10, July 15, 2024
The department may conduct a claims review for third-party liability in
	 the following manner:
(1) By reviewing
  all claims for services that could have been the result of an
  accident;
(2) By reviewing paid
  claims for assurance that any third-party liability has been
  collected;
(3) By requesting
  payment information from insurance companies to insure payment and coverage on
  claims; and
(4) By contacting
  providers to determine whether payment from a third-party liability source was
  received by the provider or recipient.
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 67:16:26 - Third-party liability › Section 67:16:26:10 - 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 67:16:28 - Ambulatory surgical centers (ASCs) › Section 67:16:28:00 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Ambulatory surgical center" or "ASC," a
  facility which operates exclusively for the purposes of providing surgical
  services to patients not requiring hospitalization.
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 67:16:28 - Ambulatory surgical centers (ASCs) › Section 67:16:28:01 - Eligible ambulatory surgical centers

Current through Register Vol. 51, page 10, July 15, 2024
Reimbursement for ambulatory surgical center (ASC) services under this
	 chapter is limited to a facility which is not a hospital and which is an
	 approved ASC provider under Medicare.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Eligible facilities,
		42 C.F.R. §
												416.25
		(a).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:28 - Ambulatory surgical centers (ASCs) › Section 67:16:28:02 - Services included in ASC reimbursement

Current through Register Vol. 51, page 10, July 15, 2024
The ASC facility services that are reimbursable under this chapter
	 include services such as the following:
(1) Nursing, technician, and related
  services;
(2) Use of ASC
  facilities;
(3) Drugs, biologicals,
  surgical dressings, supplies, splints, casts, and appliances and equipment
  directly related to the provision of surgical procedures;
(4) Diagnostic or therapeutic services or
  items directly related to the provision of surgical procedures;
(5) Administrative and recordkeeping
  services;
(6) Housekeeping items
  and supplies; and
(7) Materials for
  anesthesia.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
ASC facility services,
		42 C.F.R. §
												416.61
		(c).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:28 - Ambulatory surgical centers (ASCs) › Section 67:16:28:03 - Services not included in ASC reimbursement

Current through Register Vol. 51, page 10, July 15, 2024
ASC facility services reimbursable under this chapter do not include
	 items and services for which payment may be made under other provisions of this
	 article, such as physician services, laboratory services, X ray or diagnostic
	 procedures, prosthetic devices, ambulance services, orthotic devices, and
	 durable medical equipment for use in the patient's home, unless they are
	 specifically included under §
									67:16:28:02.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
ASC facility services not included,
		42 C.F.R. §
												416.61.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:28 - Ambulatory surgical centers (ASCs) › Section 67:16:28:04 - Surgical services covered

Current through Register Vol. 51, page 10, July 15, 2024
Surgical procedures covered under this chapter are limited to those
	 procedures contained on the department's fee schedule website.
The procedures 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.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:28 - Ambulatory surgical centers (ASCs) › Section 67:16:28:05 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
The rate of payment for the different groups of covered ambulatory
	 surgical center services is contained on the department's fee schedule
	 website.
The rates of payment for the different groups 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,
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:28 - Ambulatory surgical centers (ASCs) › Section 67:16:28:06 - Payment for multiple procedures

Current through Register Vol. 51, page 10, July 15, 2024
If one covered surgical procedure is performed in a single operative
	 session, payment is 100 percent of the established reimbursement rate. If more
	 than one surgical procedure is performed in a single operative session, the
	 procedure with the highest reimbursement rate is covered at 100 percent of the
	 established rate and each additional procedure is covered at 50 percent of the
	 established reimbursement rate.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Rate of payment, 42 C.F.R. §
												416.120
		(c).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:28 - Ambulatory surgical centers (ASCs) › Section 67:16:28:07

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 67:16:28 - Ambulatory surgical centers (ASCs) › Section 67:16:28:08 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for ASC services shall be provided by the
	 following:
(1) Computerized claims
  processing;
(2) Postpayment
  monitoring; 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 67:16:28 - Ambulatory surgical centers (ASCs) › Section 67:16:28:09 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim submitted under this chapter must be submitted at the
	 provider's usual and customary charge.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:28 - Ambulatory surgical centers (ASCs) › Section 67:16:28:10 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for services provided under this chapter must be submitted on
	 a form which contains the following information:
(1) The recipient's full name;
(2) The recipient's medical assistance
  identification number from the recipient's medical assistance identification
  card;
(3) Third-party liability
  information required under chapter 67:16:26;
(4) Date of service;
(5) Place of service;
(6) The provider's usual and customary
  charge. The provider may not subtract other third-party or cost-sharing
  payments from this charge;
(7) The
  applicable procedure codes as contained in either
CMS Common Procedure
  Coding System
(HCPCS) or the
Physicians' Current Procedural
  Terminology
(CPT) for services covered under §
									67:16:28:04;
(8) The units of service furnished, if more
  than one; and
(9) The provider's
  name and medical assistance identification number.
A separate claim form must be used for each recipient.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Note:
The CMS 1500 form substantially meets the
		requirements of this rule and its content and appearance are acceptable to the
		department. These forms are available for direct purchase through the
		Superintendent of Documents, U.S. Government Printing Office, Washington, D.C.
		20402. (202) 783-3238 - pricing desk.
Claims, ch 67:16:35.
Use of CPT, §
											67:16:01:25.
Use of HCPCS, §
											67:16:01:27.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:28 - Ambulatory surgical centers (ASCs) › Section 67:16:28:11 - 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 67:16:28 - Ambulatory surgical centers (ASCs) › Appendix A - List of Covered Ambulatory Surgical Procedures, repealed, 35 SDR 49, effective September 10, 2008

Current through Register Vol. 51, page 10, July 15, 2024
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:29 - Medical equipment › Section 67:16:29:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
"Maintenance," servicing performed at routine intervals based on hours
	 of use or calendar days to ensure that equipment is in working order;
(1) "Medical equipment," equipment which
  withstands repeated use, is primarily and customarily used to serve a medical
  purpose, generally is not useful to a person in the absence of illness or
  injury, is appropriate for use in the recipients home;
(2) "Medical supplies" health care related
  items that are consumable or disposable that are required for care of a medical
  condition. This does not include personal care items (such as deodorants,
  talcum powders, bath powders, soaps, eyewashes, contact solutions) or oral or
  injectable over-the-counter drugs and medications;
(3) "Repair," parts and labor necessary to
  restore a piece of medical equipment to its original working order, but not
  add-on equipment or enhancements;
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2)(4)(6).
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 - Medical equipment covered

Current through Register Vol. 51, page 10, July 15, 2024
Covered medical equipment includes medical equipment, prosthetic
	 devices, and medical supplies required to improve the functioning of a
	 malformed body part or treatment of an illness or injury that are listed on the
	 department's fee schedule website and prescribed by a physician or other
	 licensed practitioner. The recipient's condition must meet the coverage
	 criteria listed on the department's billing guidance website for the item to be
	 covered. Items not specifically listed may not be covered by South Dakota
	 Medicaid. Documentation substantiating the recipient's condition must be on
	 file with the provider. Items requiring prior authorization are listed on the
	 department's prior authorization website.
Supplies necessary for the effective use or proper functioning of
	 covered medical equipment are covered when:
(1) The equipment is covered by
  Medicaid;
(2) The recipient's
  condition meets the coverage criteria for equipment; and
(3) The equipment is owned by the recipient.
Supplies for rented durable medical equipment are included in the
	 Medicaid rental payment, unless specifically listed on the department's billing
	 guidance website.
In addition to the specific limits established in this chapter,
	 replacement of medical equipment is allowed only when a medical condition
	 exists which necessitates the replacement of the particular piece of equipment.
	 The prescribing physician or other licensed practitioner must determine whether
	 a medical necessity exists and must document the need on the prescription for
	 the replacement equipment.
Non-covered items may be requested by the recipient's physician or
	 other licensed practitioner. Requests for non-covered items must demonstrate
	 medical necessity and be prior authorized by the department.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Limits on the provision of medical equipment and supplies, §
											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 67:16:29:02.01

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.