reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:08 - Services not covered

Current through Register Vol. 51, page 10, July 15, 2024
Services not covered under this chapter include the following:
(1) Nutritional supplementation for
  individuals 21 years of age or older, unless the recipient has a diagnosis
  consistent with inborn errors of metabolism; and
(2) Nutritional therapy or supplementation
  for situations involving temporary impairment, such as a nutritional crisis
  during pregnancy.
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 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:09 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment for nutritional items and supplies is the lesser of the
	 provider's usual and customary charge or the applicable fee established on the
	 department's fee schedule website. If no fee is specified for nutritional
	 formulas, payment is limited to 60 percent of the provider's usual and
	 customary charge. Supplies and administration kits are paid at 90 percent of
	 the provider's usual and customary charge.
The nutritional items and supplies and their 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,
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:10

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 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:11 - Limit on costs

Current through Register Vol. 51, page 10, July 15, 2024
If the recipient requires regular or routine medical services in
	 addition to the nutritional therapy or nutritional supplements provided under
	 this chapter, the cost of all the services provided in the home may not exceed
	 135 percent of the cost of institutional care.
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 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:12 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
A provider submitting a claim for reimbursement under this chapter must
	 submit the claim at the provider's usual and customary charge.
Costs of professional intervention services, such as nursing and
	 dietary, which are pertinent to the parenteral therapy are included in the cost
	 of the parenteral therapy.
The claim must contain the applicable procedure codes for the items and
	 services provided.
Claims for enteral therapy services for individuals age 21 and older
	 and parenteral therapy may not be submitted unless the provider obtained
	 approval from the department before the services were provided.
A claim for intermittent home health skilled nursing visits must meet
	 the requirements of chapter 67:16:05.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:13 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for nutritional items and supplies 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 the items and services provided;
(8) The units of service furnished, if more
  than one;
(9) The provider's name
  and National Provider Identification (NPI) number; and
(10) If applicable, the prior authorization
  number issued to the provider by the department. 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 is acceptable. These
		forms are available for direct purchase through the Superintendent of
		Documents, U.S. Government Printing Office, Washington, D.C. 20402. (202)
		783-3238 - pricing desk.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:14 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
The department may conduct utilization reviews of nutritional therapy
	 and nutritional supplements during computerized claims processing and
	 postpayment review.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:15 - Application of other chapters

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the rules contained in this chapter, providers and
	 recipients must meet the requirements of chapters 67:16:01, 67:16:26, 67:16:33,
	 67:16:34, 67:16:35, and if applicable, 67:16:39.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:42 - Nutritional therapy and nutritional supplements › Appendix A - List of Procedure Codes and Prices for Enteral Therapy, Oral Nutrition, and Electrolyte Replacement for Individuals Under 21 Years of Age, 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 67:16:42 - Nutritional therapy and nutritional supplements › Appendix B - List of Procedure Codes and Prices for Enteral Therapy for Individuals Age 21 and Older, 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 67:16:42 - Nutritional therapy and nutritional supplements › Appendix C - List of Procedure Codes and Prices for Parenteral Therapy, 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 67:16:43 - Care management - Medically complex children › Section 67:16:43:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Care management," the monitoring of
  admissions to the medically complex program to assure the medical necessity of
  the admission, monitor the need for a continued stay in the program, and assist
  in facilitating a child's discharge from the program;
(2) "Care manager," a registered nurse
  employed by or under contract with the Department of Social Services who is
  responsible for care management;
(3) "Care plan," a written plan of care
  designed for a particular child and prepared by an interdisciplinary
  team;
(4) "Child," a person under
  the age of 21;
(5) "Complex medical
  care," care requiring professional nursing on a 24-hour basis that can only be
  done by or under the direction of a professional nurse;
(6) "Facility," a specialized hospital
  providing services under this chapter;
(7) "Interdisciplinary team," a team
  consisting of professionals involved in the child's care, the child's parent,
  guardian, or other authorized representative, and the child, if
  appropriate;
(8) "Medically complex
  care program," an inpatient program provided by a specialized hospital for a
  child who does not require acute care hospitalization but who cannot be cared
  for at home because of the need for complex medical care on a 24-hour basis;
  and
(9) "Specialized hospital," a
  facility licensed by the Department of Health which provides only one service
  or a combination of services but which does not provide all of the services
  required to qualify as a general hospital.
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 67:16:43 - Care management - Medically complex children › Section 67:16:43:02 - Children subject to care management

Current through Register Vol. 51, page 10, July 15, 2024
A child who is eligible for medical assistance and is in need of
	 complex medical care is subject to care management.
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 67:16:43 - Care management - Medically complex children › Section 67:16:43:03 - Authorization for admission required

Current through Register Vol. 51, page 10, July 15, 2024
A facility must have authorization from the care manager before
	 admitting a child to a medically complex program. The care manager shall use
	 the criteria contained in §
									67:16:43:04 to determine if the
	 child can be admitted.
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 67:16:43 - Care management - Medically complex children › Section 67:16:43:04 - Admission requirements

Current through Register Vol. 51, page 10, July 15, 2024
Admission to a medically complex program is a covered service if the
	 following criteria are met:
(1)
  Medical documentation substantiates that the service is medically necessary.
  Medical documentation includes a diagnosis, a complete medical history, copies
  of progress notes from physicians or other professionals providing care or
  services, laboratory tests, X rays, physician or other licensed practitioner
  orders and a treatment plan outlining the needed care, and any other
  documentation which may be necessary to determine medical necessity for the
  child's admission;
(2) Home health
  care is not a viable option as determined by the department based on the
  child's medical needs, the availability of home health services, and cost
  effectiveness;
(3) The facility has
  notified the child's school district that the child has been referred to the
  facility for services and may be in need of an educational program;
(4) The cost of care does not exceed the cost
  of care in the child's home; and
(5) Professional nursing services are
  necessary on a 24-hour basis and the child requires at least two of the
  following services:
(a) Intravenous
  medications more than twice a day which must be administered by a registered
  nurse;
(b) Drug therapy
  stabilization which requires skilled monitoring on a 24-hour basis;
(c) Nutritional therapy during an unstable
  period;
(d) Alternative nutritional
  feeding, such as nasogastric or gastrostomy feeding, during an unstable
  period;
(e) Tracheostomy care
  during an unstable period;
(f)
  Colostomy or ileostomy care during an unstable period;
(g) Skilled skin care and monitoring for the
  treatment of a decubitus ulcer;
(h)
  Monitoring of oxygen saturation when oxygen is being administered;
(i) Skilled nursing observation and
  assessment following casting or surgeries;
(j) Direct paraprofessional care for more
  than eight hours a day which is supervised by a medical professional;
(k) Peritoneal dialysis during an unstable
  period;
(l) Infectious disease care
  during an unstable period;
(m) Use
  of a ventilator during an unstable period; or
(n) Professional monitoring to manage end
  stage disease process.
For purposes of this rule, an unstable period is that period of time
	 necessary for a child to return to a medically stable state following a disease
	 process, illness, or surgery.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:43 - Care management - Medically complex children › Section 67:16:43:05 - Care plan requirements

Current through Register Vol. 51, page 10, July 15, 2024
The interdisciplinary team must prepare a care plan for each child
	 admitted under the provisions of this chapter. The care plan must contain at
	 least the following information:
(1) A
  description of the medically necessary health care services needed by the
  child;
(2) The frequency and
  duration of the needed services;
(3) The estimated length of stay;
  and
(4) The expected outcome of the
  needed services.
The facility must prepare the care plan and submit it to the care
	 manager within 24 hours after the child is admitted or by the first working day
	 after the date of admission, whichever is later.
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 67:16:43 - Care management - Medically complex children › Section 67:16:43:06 - Care manager to review and approve the need for continued stay

Current through Register Vol. 51, page 10, July 15, 2024
After the care manager approves an admission, the care manager shall
	 review the child's medical records to determine whether the child's condition
	 justifies continued care in the facility. A child continues to be eligible for
	 the medically complex program as long as the requirements contained in §
									67:16:43:04 are
	 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 67:16:43 - Care management - Medically complex children › Section 67:16:43:07 - Criteria for discharge

Current through Register Vol. 51, page 10, July 15, 2024
A child's care in the medically complex program is no longer a covered
	 service when the care manager determines that the child's condition has
	 stabilized and the criteria contained in §
									67:16:43:04 are no longer met or
	 the direct professional and paraprofessional care needs may be met by the
	 family or by the family with home health intervention.
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 67:16:43 - Care management - Medically complex children › Section 67:16:43:08 - Rate of payment - Limits

Current through Register Vol. 51, page 10, July 15, 2024
Payment is subject to the following restrictions:
(1) Payment is limited to days the child is
  actually in the facility;
(2)
  Payment is made for the day of admission but not the day of
  discharge;
(3) Payment may not be
  made for reserved bed days;
(4)
  Except for subdivision (2) of this section, payment may not be made for partial
  days; and
(5) Payment may not be
  made for day programs.
Rates of payment are established under the provisions of §
										67:16:03:06.06.
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 67:16:43 - Care management - Medically complex children › Section 67:16:43:09 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for services provided under this chapter must be submitted on
	 a form which contains the following information:
(1) The child's full name;
(2) The child's medical assistance
  identification number from the child's medical identification card;
(3) Third-party liability information
  required under chapter 67:16:26;
(4) Date of service;
(5) The provider's current daily rate. The
  provider may not subtract other third-party or cost-sharing from this
  charge;
(6) Units of service
  furnished, if more than one;
(7)
  The applicable diagnosis codes adopted in §
									67:16:01:26;
(8) The provider's name and National Provider
  Identification (NPI)number;
(9)
  Type of admission;
(10) The prior
  authorization number assigned by the care manager;
(11) The revenue code; and
(12) The type of bill.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Note:
The CMS 1450 (UB-04) forms are available for
		direct purchase through the Superintendent of Documents, U.S. Government
		Printing Office, Washington, D.C. 20402. (202) 783-3238 - pricing
		desk.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:43 - Care management - Medically complex children › Section 67:16:43:10 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
When submitting a claim under this chapter, a facility may bill only
	 for the number of days a child is actually in the facility.
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 67:16:43 - Care management - Medically complex children › Section 67:16:43:11 - 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, 67:16:35, and 67:16:39.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
As used in this article:
(1)
  "Federally qualified health center" means an entity that meets the requirements
  set forth in 42 C.F.R.
  §
										405.2401, as amended to July 1,
  2017;
(2) "Provider" means a
  federally qualified health center or a rural health clinic;
(3) "Rural health clinic" means a facility
  that meets the requirements set forth in
  42 C.F.R. §
										405.2401, as amended to July 1,
  2019;
(4) "Telehealth" means a
  method of delivering services including interactive audiovisual or audio-only
  technology, in accordance with SDCL
  34-52-1; and
(5) "Visit" means a face-to-face or
  telehealth encounter between a federally qualified health center or rural
  health clinic patient and a physician, physician assistant, nurse practitioner,
  nurse midwife, visiting nurse, mental health provider listed in §
									67:16:41:03, dentist, or an
  accredited substance use disorder provider.
General Authority:
SDCL
		28-6-1(1)(2)(4).
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:02 - Covered services

Current through Register Vol. 51, page 10, July 15, 2024
Services covered under this chapter are limited to services which meet
	 the following criteria:
(1) Medically
  necessary services covered under the provisions of chapters 67:16:01, 67:16:02,
  67:16:06, 67:16:11, 67:16:12, 67:16:41, and 67:16:48;
(2) Provided to a recipient at a FQHC, RHC,
  or other outpatient setting, including the recipient's place of residence or a
  skilled nursing facility. Services provided at an inpatient or outpatient
  hospital are not covered; and
(3)
  Provided under the medical direction of a physician.
General Authority:
SDCL 28-6-1(1)(2).
Law Implemented:
SDCL
		28-6-1(1)(2).
Scope of benefits - Clinic,
		42 C.F.R. §
												405.2411.
Scope of services - Center,
		42 C.F.R. §
												405.2446.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:03

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 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:04

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Medicare Rural Health Clinic and Federally Qualified Health
		Center Manual
(HCFA Pub. 27), October 1992. United States Department of
		Health and Human Services, Health Care Financing Administration. For sale by
		the Superintendent of Documents, United States Government Printing Office,
		Washington, D.C. 20402; $115.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:05 - Required cost reports

Current through Register Vol. 51, page 10, July 15, 2024
A provider must submit to the Department of Social Services, Office of
	 Provider Reimbursement and Audits, a completed copy of the provider's cost
	 report showing the actual costs incurred during the reporting period and the
	 total number of visits for the services furnished as required in chapter 29 of
	 the
Independent Rural Health Clinic and Freestanding Federally Qualified
	 Health Center Cost Report Form
CMS-222-92, as amended to July 1, 2019.
	 The provider must submit the required cost report to the department within five
	 months after the provider's fiscal year ends.
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 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:06 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment is made at an all-inclusive rate for each visit for covered
	 services. The department follows the standards established by the Medicare,
	 Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000,
	 Title II, § 702 (114 Stat. 2763A-572), as amended to July 1, 2019, to
	 determine a facility's rate of payment.
In the absence of specific regulations relating to allowable costs, the
	 department bases allowable cost decisions on the
Medicare Provider
	 Reimbursement Manual
(CMS Pub. 15-1), as specified in §
									67:16:04:62.
Covered services that are not reimbursed as part of the all-inclusive
	 rate will be reimbursed at the applicable medical assistance reimbursement
	 methodology for the service.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
Definition of rural primary care hospital, SDCL
		34-12-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:07 - Payment limitations

Current through Register Vol. 51, page 10, July 15, 2024
Payments at an all-inclusive rate to a FQHC or RHC are subject to the
	 following limitations:
(1) Encounters
  with more than one health professional and multiple encounters with the same
  health professional which take place on the same day constitute a single visit,
  unless the visit meets the criteria stated in subdivision (2) of this
  section;
(2) Payment is limited to
  two visits a day. The second visit is payable only if, after the first visit,
  the patient suffers illness or injury which requires additional diagnosis or
  treatment, one of the visits is for behavioral health services covered under
  the provisions of 67:16:41 or 67:16:48, or one of the visits is for dental
  services provided under the provisions of 67:16:06;
(3) Payment is limited to those covered
  services provided by a physician, physician assistant, nurse practitioner,
  visiting nurse, mental health provider listed in §
									67:16:41:03, dentist, or an
  accredited substance use disorder provider.
General Authority:
SDCL
		28-6-1(1)(2).
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 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:08

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 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:09 - 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(2).
Law Implemented:
SDCL
		28-6-1(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:10 - 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 or in an electronic format that contains the following
	 information:
(1) The recipient's full
  name;
(2) The recipient's medical
  assistance identification number from the recipient's medical assistance
  identification card;
(3)
  Third-party liability information required under chapter 67:16:26;
(4) Date of service;
(5) Place of service;
(6) The provider's usual and customary
  charge. The provider may not subtract other third-party or cost-sharing
  payments from this charge;
(7) The
  applicable procedure codes contained in either Health Care Common Procedure
  Coding System (HCPCS) or Current Procedural Terminology for services covered
  under this chapter;
(8) The
  applicable diagnosis codes adopted in §
									67:16:01:26; and
(9) 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.
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 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:11

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:13 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for FQHC or RHC services may be conducted on the
	 following levels:
(1) Computerized
  claims processing;
(2) Post payment
  review; and
(3) Peer
  reviews.
General Authority:
SDCL
		28-6-1(4).
Law Implemented:
SDCL
		28-6-1(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:44 - Federally qualified health centers and rural health clinics › Section 67:16:44:14 - Application of other chapters

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the rules contained in this chapter, providers and
	 recipients must meet the requirements of chapters 67:16:01, 67:16:26, 67:16:33,
	 67:16:34, 67:16:35, and 67:16:39.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:46 - Diabetes self-management training › Section 67:16:46:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
As used in this chapter:
(1)
  "Diabetes self-management training," means a program delivered on an outpatient
  basis and designed to educate a person with diabetes in the self-management of
  diabetes.
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 67:16:46 - Diabetes self-management training › Section 67:16:46:02 - Eligibility requirements - Providers

Current through Register Vol. 51, page 10, July 15, 2024
A diabetes self-management training provider may receive reimbursement
	 for services covered under this chapter if the provider is a participating
	 provider in the medical assistance program and the program is recognized either
	 by the American Diabetes Association or the South Dakota Department of Health.
	 Neither a federally qualified health center nor a rural health center is
	 eligible to receive reimbursement for services under this
	 chapter.
General Authority:
SDCL
		28-6-1(1)(2).
Law Implemented:
SDCL
		28-6-1.
Participating provider, §
											67:16:01:05.
Providers recognized to deliver diabetes self-management education
		programs are listed at
https://doh.sd.gov/diseases/chronic/diabetes/management.aspx
.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:46 - Diabetes self-management training › Section 67:16:46:03 - Eligibility requirements - Individuals

Current through Register Vol. 51, page 10, July 15, 2024
An individual is eligible to participate in a diabetes self-management
	 training if the individual is not institutionalized, the program is provided by
	 a provider eligible under the provisions of §
									67:16:46:02, the individual has
	 not previously received diabetes self-management training, and the individual
	 meets one of the following conditions:
(1) The individual is a newly diagnosed with
  diabetes or gestational diabetes;
(2) The individual demonstrates poor glycemic
  control as evidence by glycated hemoglobin level more than 2 percent above the
  upper limit of normal for the assay used;
(3) The individual's treatment regimen has
  been changed by a physician or other licensed practitioner;
(4) The individual has documented episodes of
  acute, severe hypoglycemia or hyperglycemia occurring in the past year that
  required third-party assistance; or
(5) The individual is at high risk because of
  the presence of extremity, renal, or cardiac complications or diabetic
  retinopathy.
General Authority:
SDCL
		28-6-1(1)(4).
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:46 - Diabetes self-management training › Section 67:16:46:04 - Limit on hours of service

Current through Register Vol. 51, page 10, July 15, 2024
A diabetes self-management training is limited to the following:
(1) Ten hours of initial education
  and
(2) Two hours a year of
  follow-up education.
The department must authorize services that exceed these limits before
	 the services are provided. Authorization is based on documentation supplied to
	 the department that justifies the need for the additional
	 services.
General Authority:
SDCL
		28-6-1(1)(2).
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 67:16:46 - Diabetes self-management training › Section 67:16:46:05 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment for services covered under the provisions of this chapter is
	 limited to the procedure codes established on the department's fee schedule
	 website.
The services 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,
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:46 - Diabetes self-management training › Section 67:16:46:06 - Claim 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 contained in §
									67:16:46:05. The claim for
	 services must be submitted on a form 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 may not subtract other third-party or cost-sharing
  payments from this charge;
(7) The
  procedure codes for services covered under §
									67:16:46:05;
(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 used for each recipient.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Note:
The CMS 1500 form substantially meets the
		requirements of this rule and its content and appearance are acceptable to the
		department. These forms are available for direct purchase through the
		Superintendent of Documents, U.S. Government Printing Office, Washington, D.C.
		20402. (202) 783-3238 - pricing desk.
Claims, ch 67:16:35.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:46 - Diabetes self-management training › Section 67:16:46:07

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 67:16:46 - Diabetes self-management training › Section 67:16:46:08 - Provider must maintain and make available certain documentation

Current through Register Vol. 51, page 10, July 15, 2024
As required by the American Diabetes Association and the South Dakota
	 Department of Health, the provider must prepare an initial assessment of the
	 individual's needs, develop an education plan based on the assessment, prepare
	 reassessments as necessary to adjust to the individual's changing needs, and
	 conduct and document a post-program evaluation. The program must maintain a
	 copy of these completed documents together with a copy of the physician or
	 other licensed practitioner's order for the diabetes self-management training
	 for each recipient served and make the documents available to the department on
	 request.
General Authority:
SDCL
		28-6-1(1)(4).
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:46 - Diabetes self-management training › Section 67:16:46:09 - 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 67:16:46 - Diabetes self-management training › Section 67:16:46:10 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
The department may provide utilization review of diabetes
	 self-management training covered under this chapter through computerized claims
	 processing and postpayment review.
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 67:16:47 - Residential treatment for children › Section 67:16:47:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Certification team," a team of medical
  professionals that determines whether an individual is in need of psychiatric
  services;
(2) "Department," the
  Department of Social Services;
(3)
  "Juvenile detention center," a locked facility operated under the authority of
  a county that houses children who have been convicted or accused of violating
  South Dakota law;
(4) "Outpatient
  care setting," professional services provided at a participating facility that
  does not include room, board, or services provided on a 24-hour
  basis;
(5) "Placing agency," the
  agency or individual responsible for referring a person to the state review
  team for possible placement into a residential treatment setting;
(6) "Provider," a facility described in
  §
									67:16:47:02 or
  67:16:47:03 that has entered into
  an agreement with the department to provide residential treatment services
  under the provisions of this chapter; and
(7) "Treatment team," the team established
  under the provisions of §
									67:42:08:05 or
  67:42:15:09, as applicable, that
  plans, provides, and monitors services to a child in residential care and the
  childs family.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		26-6-14,
		28-6-1.
DSM-IV-TR -- Diagnostic and Statistical Manual of Mental
		Disorders
, Fourth Edition, Text Revision, published by the American
		Psychiatric Association, 1400 K Street, N.W., Washington, D.C. 20005;
		$57.95.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:47 - Residential treatment for children › Section 67:16:47:02 - Facilities eligible for reimbursement - In-state

Current through Register Vol. 51, page 10, July 15, 2024
The following types of psychiatric residential treatment facilities are
	 eligible to receive reimbursement for services provided to individuals under
	 the age of 21:
(1) A residential
  treatment center licensed under the provisions of chapter 67:42:08;
  and
(2) An intensive residential
  treatment center licensed under the provisions of chapter 67:42:15.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL 26-6-14,
		28-6-1.
Inpatient psychiatric services for individuals under age 21 in
		psychiatric facilities or programs General requirements, §
											42 C.F.R. §
												441.151.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:47 - Residential treatment for children › Section 67:16:47:03 - Facilities eligible for reimbursement - Out-of-state

Current through Register Vol. 51, page 10, July 15, 2024
An out-of-state facility is eligible for reimbursement if the following
	 requirements are met:
(1) The facility
  has a residential treatment program for children under the age of 21;
  and
(2) The facility is a
  psychiatric residential treatment facility accredited in the area of behavioral
  health care by the Joint Commission, the area of residential treatment services
  by the Council on Accreditation, or the area of behavioral health or child and
  youth services by the Commission on Accreditation of Rehabilitation
  Facilities.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		26-6-14,
		28-6-1.
Note:
Information relating to accreditation may be
		obtained from the Joint Commission, One Renaissance Boulevard, Oakbrook
		Terrace, Illinois 60181. Their website address is
www.jointcommission.org
.
		They can be reached at (630) 792-5000 or (630) 792-5800; the Commission on
		Accreditation of Rehabilitation Facilities, 4891 E. Grant Road, Tucson, Arizona
		85712. Their website address is
www.carf.org
. They can be reached at (520)
		325-1044 or (888) 281-6531; or the Council on Accreditation, 120 Wall Street
		11th Floor, New York, New York 10005. Their website
		address is
www.coanet.org
. They can
		be reached at (212) 797-3000 or (866)
		262-8088.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:47 - Residential treatment for children › Section 67:16:47:04 - Treatment as a covered service - Conditions that must be met

Current through Register Vol. 51, page 10, July 15, 2024
Treatment at an eligible facility is a covered service if the following
	 conditions are met:
(1) The individual
  is under the age of 21 or, if treatment began before the individual reached the
  age of 21, the treatment may continue until the date it is no longer needed or
  the date the individual reaches the age of 22, whichever occurs
  earlier;
(2) The state review team
  has determined that the conditions of § 67:16:47:04.02 have been
  met;
(3) The certification team has
  certified that the requirements contained in § 67:16:47:04.04 have been
  met;
(4) The services are expected
  to improve the individuals emotional and behavioral condition or prevent
  further regression; and
(5) The
  individual is eligible for medical assistance under article 67:46.
The referring source shall gather and supply to the department the
	 documentation necessary to determine eligibility.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		26-6-14,
		28-6-1.
State review team, § 67:16:47:04.01.
Certification team, §
		67:16:47:04.03.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:47 - Residential treatment for children › Section 67:16:47:04.01 - State review team

Current through Register Vol. 51, page 10, July 15, 2024
The state review team shall consist of at least one representative from
	 each of the following state agencies:
(1) The Department of Corrections;
(2) The Department of Social Services;
  and
(3) The Department of Human
  Services.
The team may also include a representative from the Department of
	 Education if appropriate for the individual in care.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		26-6-14,
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:47 - Residential treatment for children › Section 67:16:47:04.02 - State review team - Responsibilities

Current through Register Vol. 51, page 10, July 15, 2024
In order to meet the covered service conditions of subdivision
	 67:16:47:04(2), the state review team must determine that the following
	 conditions exist:
(1) Outpatient
  services available in the community do not meet the individual's treatment
  needs; and
(2) Proper treatment of
  the individual's psychiatric condition requires services on an inpatient basis
  under the direction of a physician.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		26-6-14,
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:47 - Residential treatment for children › Section 67:16:47:04.03 - Certification team

Current through Register Vol. 51, page 10, July 15, 2024
The department shall establish a certification team to determine
	 whether an individual is in need of psychiatric services. The team must include
	 at least one physician and must be knowledgeable about the diagnosis and
	 treatment of the mental illnesses of children and of the individual's current
	 situation.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		26-6-14,
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:47 - Residential treatment for children › Section 67:16:47:04.04 - Certification team - Responsibilities

Current through Register Vol. 51, page 10, July 15, 2024
In order to meet the covered service conditions of subdivision
	 67:16:47:04(3), the certification team, based on medical documentation, must
	 certify the existence of the following:
(1) The individual requires intensive
  professional assistance and therapy for behavioral or emotional problems in the
  highly structured, self-contained environment of a residential treatment
  center, an intensive residential treatment center, or a psychiatric residential
  treatment facility;
(2) The
  services are medically necessary;
(3) The outpatient resources available in the
  community do not meet the individual's treatment needs;
(4) The proper treatment for the individual's
  mental illness requires services on an inpatient basis under the direction of a
  physician;
(5) The individual has a
  diagnosis of one of the diagnoses listed in §
									67:16:47:04.05 and is experiencing
  problems related to the diagnosis in one of the categories listed in §
									67:16:47:04.06; has a history of a
  psychiatric diagnosis and is posing an imminent danger to self or others; or,
  in the absence of an identified psychiatric diagnosis, is exhibiting symptoms
  and behavior of such severity that it places the individual or others at risk
  and warrants residential treatment under the direction of a physician;
  and
(6) The services can reasonably
  be expected to improve the individual's condition or prevent further regression
  so that the services will no longer be needed.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		26-6-14,
		28-6-1.
Covered services must be medically necessary, §
											67:16:01:06.02.