reglab/statecodes huggingface dataset:
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 67:16:47:04.05 - Diagnoses recognized for treatment

Current through Register Vol. 51, page 10, July 15, 2024
The diagnoses recognized for treatment under the provisions of this
	 chapter are limited to the following:
(1) Schizophrenia;
(2) Psychotic disorders;
(3) Depressive disorders;
(4) Bipolar disorders;
(5) Anxiety disorders;
(6) Obsessive compulsive and related
  disorders;
(7) Trauma and stressor
  related disorders;
(8) Dissociative
  disorders;
(9) Disruptive and
  impulse control disorders;
(10)
  Conduct disorders;
(11)
  Neurocognitive disorders;
(12)
  Personality disorders; and
(13)
  Other conditions not otherwise classified.
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 67:16:47:04.06 - Problems associated with diagnosis

Current through Register Vol. 51, page 10, July 15, 2024
In order to meet the conditions of subdivision 67:16:47:04.04(5), an
	 individual who has a diagnosis listed in §
									67:16:47:04.05 must also be
	 experiencing problems related to the diagnosis in one of the following
	 categories:
(1) Self-care deficit
  placing the individual at risk for self-harm. The deficit must be of such
  severity and long standing as to prevent placement of the individual in a
  community setting and without skilled intervention is placing the individual in
  a life-threatening, physiological imbalance;
(2) Impaired safety, including a threat to
  self or others, continued suicidal or homicidal ideation with a plan of intent;
  continued violent or aggressive behaviors that require seclusion or restraints;
  verbal, physical, or sexually aggressive behavior that poses a potential danger
  to self or others; or antisocial behavior of such severity that it places the
  individual or others at risk;
(3)
  Impaired thought process that results in an inability to perceive or validate
  reality to the extent that the individual cannot negotiate the individual's
  basic environment or participate in family or school life, including disruption
  of safety to self, family, or peer or community group; or impaired reality
  testing sufficient to prohibit participation in a community educational
  alternative; or
(4) Severely
  dysfunctional patterns involving the individual's family, environment, or
  behavioral processes that places the individual at risk. Documentation must
  substantiate the existence of escalating symptoms, instability, or disruption
  that is placing the individual at risk.
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 67:16:47:05 - Prior approval required for admission

Current through Register Vol. 51, page 10, July 15, 2024
Before an individual may be admitted to a facility for treatment, the
	 certification team must approve the individuals admission to the facility.
	 Approval is based on a review of the following documentation:
(1) The individuals social history that
  includes past and current behaviors that have prompted the request for
  admission to a residential facility;
(2) A psychological or psychiatric evaluation
  and diagnosis that was completed within the past 12 months, if
  available;
(3) A summary of the
  individuals behaviors during school from the individuals school district, if
  available;
(4) Copies of the
  discharge summaries from previous acute inpatient psychiatric hospitalizations,
  if applicable;
(5) A summary of
  outpatient care services that have been provided, including outcomes and
  recommendations; and
(6) An alcohol
  and drug screening assessment, if available.
The placing agency shall gather and supply to the department the
	 required documentation.
For emergency admissions, the certification team shall complete its
	 review on the first working day following the date of admission into the
	 residential treatment center.
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 67:16:47:07 - Provider responsibility - Required notice to child's placing agency

Current through Register Vol. 51, page 10, July 15, 2024
Before the provider admits an individual to a facility and each month
	 thereafter that the individual remains in care, the provider must verify
	 through the department that the individual continues to be eligible for medical
	 assistance.
The provider must notify the childs placing agency in advance of
	 treatment team meetings. In addition, the provider must notify the placing
	 agency within 24 hours after the occurrence of any of the following:
(1) The individual has been discharged from
  the facility;
(2) The individual
  has run away from the facility;
(3)
  The individual has been admitted to a hospital; or
(4) The individual has been placed in a
  juvenile detention center.
Failure to comply with the requirements of this section may result in
	 termination of coverage.
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 67:16:47:08 - Requirements for continued stay

Current through Register Vol. 51, page 10, July 15, 2024
An individuals continuous and uninterrupted stay in a facility is a
	 covered service if the certification team determines
,
based on the
	 childs progress report required by §
									67:42:08:07 or
	 67:42:15:11, that all of the
	 following conditions are met:
(1) The
  individual is actively participating in the treatment;
(2) The individual continues to require the
  authorized level of care and is not able to function or use outpatient care as
  reflected in the medical record;
(3) The individual is complying with the
  recommendations made by the treatment team; and
(4) The individuals daily progress notes show
  improvement towards the goal of discharge.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		26-6-14,
		28-6-1(1)(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:47 - Residential treatment for children › Section 67:16:47:09 - Covered services

Current through Register Vol. 51, page 10, July 15, 2024
Services covered under the provisions of this chapter are limited to
	 those authorized by the certification team.
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 67:16:47:09.01 - Nonreimbursable days

Current through Register Vol. 51, page 10, July 15, 2024
The following are not reimbursable under the provisions of this
	 chapter:
(1) The day of
  discharge;
(2) Days the individual
  is in a juvenile detention center; and
(3) Days when the individual is absent from
  the facility for nonmedical reasons.
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 67:16:47:10 - Termination of coverage

Current through Register Vol. 51, page 10, July 15, 2024
An individuals care becomes a noncovered service when the certification
	 team determines that one of the following has occurred:
(1) The individual has reached maximum
  potential in the current setting
;
(2) The facility failed to provide the
  documentation required in §
									67:16:47:08; or
(3) The individual is no longer
  eligible.
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 67:16:47:11 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
The department shall establish a provider's rate of payment. The
	 payment shall be provider specific and contained in the providers contract with
	 the department. The department shall base the rate on historical cost data for
	 an existing provider and on prospective cost statements for a new
	 provider
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 67:16:47:12 - 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 individuals full name and
  identification number as they appear on the individuals medical assistance
  identification card;
(2)
  Third-party liability information required under chapter 67:16:26;
(3) The date of service;
(4) The place of service;
(5) The type of service;
(6) The providers usual and customary charge.
  The provider may not subtract other third-party payments from this
  charge;
(7) The units of service
  furnished, if more than one;
(8)
  The procedure code T2048;
(9) The
  providers name, address, and telephone number;
(10) The facilitys medical assistance
  identification number;
(11) The
  signature of the provider or providers representative and the date of the
  signature; and
(12) The prior
  authorization number issued by the department.
A separate claim must be submitted for each recipient.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		26-6-14,
		28-6-1.
Note:
The CMS 1500 form 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. 20401. Pricing
		information may be obtained by calling (202)
		783-3238.
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 67:16:47:13 - 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
		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 67:16:47:14 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
The department may conduct utilization reviews on the following three
	 levels:
(1) Computerized claims
  processing;
(2) Post payment
  review; and
(3) Peer
  review.
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 67:16:48 - Treatment for substance use disorders › Section 67:16:48:02 - Covered services

Current through Register Vol. 51, page 10, July 15, 2024
Substance use disorder treatment services covered under this chapter
	 are limited to the following:
(1) The
  integrated assessment;
(2) Crisis
  intervention services;
(3) Early
  intervention services;
(4)
  Outpatient treatment programs;
(5)
  Intensive outpatient treatment programs;
(6) Day treatment programs;
(7) Clinically-managed low-intensity
  residential treatment programs;
(8)
  Medically-monitored intensive inpatient treatment programs; and
(9) Psychiatric residential treatment
  programs for substance use disorders.
General Authority:
SDCL
		28-6-1(1).
Law Implemented:
SDCL
		28-6-1(1).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:48 - Treatment for substance use disorders › Section 67:16:48:03 - Services not covered

Current through Register Vol. 51, page 10, July 15, 2024
The following services are not covered under the provisions of this
	 chapter:
(1) Treatment for a diagnosis
  of substance use disorder that exceeds the limits established by the division,
  unless prior authorization is approved by the division;
(2) Out-of-state substance use disorder
  treatment unless the division determines that appropriate in-state treatment is
  not available;
(3) Treatment for a
  gambling disorder;
(4) Room and
  board for residential services;
(5)
  Substance use disorder treatment before the integrated assessment is
  completed;
(6) Substance use
  disorder treatment after 30 days if the treatment plan has not been
  completed;
(7) Substance use
  disorder treatment if a required review has not been completed;
(8) Court appearances, staffing sessions, or
  treatment team appearances; and
(9)
  Substance use disorder services provided to a recipient incarcerated in a
  correctional facility.
General Authority:
SDCL
		28-6-1(1)(4).
Law Implemented:
SDCL
		28-6-1(1)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:48 - Treatment for substance use disorders › Section 67:16:48:04 - Services requiring prior authorization

Current through Register Vol. 51, page 10, July 15, 2024
The following services require prior authorization:
(1) Medically-monitored intensive inpatient
  programs;
(2) Clinically-managed
  low intensity residential treatment programs for pregnant women or women with
  dependent children;
(3) Intensive
  methamphetamine services; and
(4)
  Psychiatric residential treatment programs.
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 67:16:48 - Treatment for substance use disorders › Section 67:16:48:05 - Prior authorization requirements

Current through Register Vol. 51, page 10, July 15, 2024
The requirements for prior authorization of a medically monitored
	 intensive inpatient program, clinically-managed low-intensity residential
	 treatment program for pregnant women or women with dependent children, and
	 intensive methamphetamine services are as follows:
(1) An addiction counselor completes an
  integrated assessment, the assessment indicates a diagnosis of a substance use
  disorder, and the addiction counselor determines the recipient meets the
  criteria for placement in, transfer to, or continued stay in a substance use
  disorder treatment program;
(2) A
  physician or other licensed practitioner refers the recipient for placement in,
  transfer to, or continued stay in a substance use disorder treatment program
  and provides the division with written verification of pregnancy, if
  applicable; and
(3) The division
  authorizes the treatment.
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 67:16:48 - Treatment for substance use disorders › Section 67:16:48:06 - Prior authorization for psychiatric residential treatment programs for substance use disorders

Current through Register Vol. 51, page 10, July 15, 2024
The requirements for prior authorization of a psychiatric residential
	 treatment program for a substance use disorder are as follows:
(1) An addiction counselor completes an
  integrated assessment, the assessment indicates a diagnosis of a substance use
  disorder, and the addiction counselor determines the adolescent meets the
  criteria for placement in, transfer to, or continued stay in a substance use
  disorder treatment program;
(2) A
  physician or other licensed practitioner refers the adolescent for placement
  in, transfer to, or continued stay in a substance use disorder treatment
  program;
(3) The division
  authorizes the treatment; and
(4)
  The certification team, based on medical documentation, determines the
  treatment is medically necessary and meets the requirements listed in
  42 CFR
  441.152, as amended to July 1, 2016. The
  certification team shall notify the division of their determination that
  medical necessity has been met or if the adolescent does not meet the severity
  of illness criteria.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
Treatment for an adolescent with a substance use disorder
		--Out-of-state, §
											67:16:48:08.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:48 - Treatment for substance use disorders › Section 67:16:48:07

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:48 - Treatment for substance use disorders › Section 67:16:48:08 - Treatment for a substance use disorder - Out-of-state

Current through Register Vol. 51, page 10, July 15, 2024
Out-of-state treatment for a substance use disorder is limited to those
	 services provided in a facility which is licensed or accredited in another
	 state as a substance use disorder treatment facility. Treatment is covered if
	 the following additional requirements are met:
(1) An addiction counselor within that state
  completes an integrated assessment and sends the completed assessment to the
  division. The assessment must include a biopsychosocial history with
  appropriate testing instrument scores, indicate a diagnosis of a substance use
  disorder, and contain the credentials of the counselor completing the
  assessment;
(2) For intensive
  inpatient treatment or psychiatric residential treatment, a physician or other
  licensed practitioner refers the recipient for placement in, transfer to, or
  continued stay in a substance use disorder treatment program;
(3) The division authorizes the treatment,
  and no appropriate in-state treatment is available; and
(4) The psychiatric residential treatment
  provided meets the prior authorization requirements found in §
									67:16:48:06.
Out-of-state outpatient services do not require prior authorization
	 when provided within 50 miles of the South Dakota border.
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 67:16:48 - Treatment for substance use disorders › Section 67:16:48:09

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:48 - Treatment for substance use disorders › Section 67:16:48:10

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:48 - Treatment for substance use disorders › Section 67:16:48:11 - Prior authorization required for care beyond established service limit

Current through Register Vol. 51, page 10, July 15, 2024
The division must prior authorize a continued stay beyond the
	 length-of-stay service limits. The provider must submit to the division the
	 documentation required in §
									67:61:07:07. Based on the
	 documentation submitted, the division shall determine whether the recipient's
	 current level of care is appropriate.
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 67:16:48 - Treatment for substance use disorders › Section 67:16:48:12 - Rate of payment - Treatment for a substance use disorder

Current through Register Vol. 51, page 10, July 15, 2024
A service covered under this chapter is subject to the limits listed
	 on the department's billing guidance website. Payment for the treatment of a
	 substance use disorder covered under this chapter is limited to the provider's
	 usual and customary charge or the fee established by the division, whichever is
	 less. The covered procedures and the associated procedure codes are found on
	 the department's fee schedule website.
The services described in §
									67:61:18:02 are included in the
	 daily rate.
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 67:16:48 - Treatment for substance use disorders › Section 67:16:48:13 - Claim requirements - Substance use disorders

Current through Register Vol. 51, page 10, July 15, 2024
A claim for a substance use disorder treatment service provided under
	 this chapter must be submitted to the department on a form or in an electronic
	 format 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 for the covered services provided;
(8) The applicable diagnosis codes as adopted
  in §
									67:16:01:26;
(9) The units or days of service furnished,
  if more than one;
(10) The
  provider's name and National Provider Identification (NPI) number;
  and
(11) The prior authorization
  number issued to the provider by the division for services that require prior
  authorization.
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 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 67:16:48 - Treatment for substance use disorders › Section 67:16:48:14 - Recognizing a tribal program as a participating provider

Current through Register Vol. 51, page 10, July 15, 2024
A tribal substance use disorder treatment program seeking to
	 participate as a provider under the provisions of this chapter shall submit all
	 of the following information to the division:
(1) A written request from the tribal
  chairman to the secretary of the department requesting permission for the
  program to provide services to a recipient under this chapter;
(2) A copy of the last onsite review
  conducted by Indian Health Services that indicates the program obtained the
  minimum points necessary to provide services for the level of care being
  provided;
(3) A written statement
  signed by the program director that states the program has met the minimum
  national or applicable state or Indian Health Services' standards for the level
  of care provided and a statement that the program is in good standing with
  Indian Health Services;
(4) A copy
  of the contract the tribe has with Indian Health Services under the provisions
  of Pub. L. 93-638 (the Indian Self-Determination Act), effective January 4,
  1975; and
(5) A copy of the signed
  provider agreement between the Department and the tribe.
The division may not recognize a tribal program as a participating
	 provider until the division is in possession of all the documentation required
	 in this section. Recognition of a tribal program is subject to annual review
	 and approval by the division.
General Authority:
SDCL
		28-6-1(4)(6).
Law Implemented:
SDCL
		28-6-1(4)(6).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:48 - Treatment for substance use disorders › Section 67:16:48:15 - 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, 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 67:16:49 - NON-EMERGENCY MEDICAL TRAVEL SERVICES › Section 67:16:49:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Charitable organization," a provider
  that has an agreement with the department to advance expenses for non-emergency
  medical travel services on behalf of Medicaid recipients. A charitable
  organization shall not act as a community transportation provider for the same
  trip;
(2) "Child," an individual up
  to the age of 21 who is a recipient of medical services under article
  67:16;
(3) "Commercial Carrier" a
  provider of non-emergency medical travel services. A commercial carrier does
  not include a community transportation provider, a charitable organization, a
  secure medical transportation provider, or an ambulance provider;
(4) "Escort," a person who accompanies a
  recipient during travel to a medical provider because the recipient is under
  age 18 or accompanied travel is medically necessary;
(5) "Private automobile," non-emergency
  medical travel services provided by a recipient, escort, or volunteer driver
  using a privately owned or leased automobile for private travel services. A
  vehicle owned by a business, non-profit organization, charitable organization,
  or governmental entity is not considered a private automobile;
(6) "Volunteer driver," an individual who
  owns, leases, or has access to a private automobile and provides transportation
  for a recipient when the recipient or escort is unable to provide
  transportation.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:49 - NON-EMERGENCY MEDICAL TRAVEL SERVICES › Section 67:16:49:02 - Travel requirements

Current through Register Vol. 51, page 10, July 15, 2024
Travel services must meet the following requirements:
(1) Travel is from an eligible recipient's
  city of residence to a medical provider located in another city, between
  medical providers located in different cities, or from a medical provider
  located in one city to the recipient's city of residence. If the recipient's
  city of residence does not have a commercial carrier or if a commercial carrier
  located in another city is less costly, the department shall pay the
  recipient's travel expenses from the recipient's city of residence to the
  commercial carrier under provisions of §
									67:16:49:03;
(2) Travel is to or from medically necessary
  examinations or treatment when the services are covered under article 67:16 or
  chapter 67:46:10 and provided by a provider who is enrolled or eligible for
  enrollment in the medical assistance program; or the travel is between a
  medical provider and the recipient's city of residence and is for the purpose
  of allowing a parent or guardian to travel to visit a minor who is a recipient,
  in a hospital or medical facility, and receiving medically necessary services
  covered under article 67:16 and the travel is necessary to meet the
  requirements of the child's service care plan;
(3) Travel 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 the
  recipient's medical provider; or travel is for a visit referred to in
  subdivision (2) of this section; and
(4) If travel is via a commercial carrier,
  the department has worked with the commercial carrier to arrange the travel and
  prior authorized the service. Reimbursement for commercial carrier travel not
  arranged with the department may be reimbursed at the departments discretion.
At its discretion the department may pay for transportation services
	 not meeting the conditions of this section if paying for the services results
	 in an overall cost savings for the department.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:49 - NON-EMERGENCY MEDICAL TRAVEL SERVICES › Section 67:16:49:03 - Covered services

Current through Register Vol. 51, page 10, July 15, 2024
Travel services are limited to the following items, which must meet
	 the requirements of §
									67:16:49:02:
(1) Mileage if the transportation is outside
  the recipient's city of residence and provided when all other means of
  available transportation are of the same or greater cost and the availability
  of transportation at no cost to the department does not exist;
(2) Mileage when the transportation is
  outside the recipient's city of residence to transport a recipient who is being
  discharged from a hospital or medical facility;
(3) Mileage driven by a volunteer driver who
  lives in another city and drives to the recipient's city of residence to
  transport the recipient when there is no other means of transporting the
  recipient;
(4) Mileage if the
  transportation is outside the recipient's city of residence and the escort or
  volunteer driver is returning to the point of origin after delivering the
  recipient to a medical provider;
(5) Mileage driven by a parent or guardian to
  travel to visit a child who is in a hospital or medical facility and receiving
  medically necessary services covered under article 67:16 or chapter 67:46:10
  and the travel is necessary to meet the requirements of the child's service
  care plan;
(6) Lodging for travel
  to or from a medical provider if the provider is at least 150 miles from the
  recipient's city of residence and travel is to obtain specialty care or
  treatment that results in an overnight stay. Lodging is limited to 14 days for
  each medical stay unless the department prior authorizes additional days. A
  recipient may not receive reimbursement for lodging for days the recipient is
  an inpatient in a hospital or medical facility; and
(7) Meals for travel to or from a medical
  provider if the provider is outside the recipient's city of residence and
  travel is to obtain specialty care or treatment that results in an overnight
  stay. Meals are limited to 14 days for each medical stay unless the department
  prior authorizes additional days. A recipient may not receive reimbursement for
  meals for days the recipient is an inpatient in a hospital or medical facility.
At its discretion the department may pay for transportation services
	 not meeting the conditions of this section if paying for the services results
	 in an overall cost savings for the department.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:49 - NON-EMERGENCY MEDICAL TRAVEL SERVICES › Section 67:16:49:04 - Services not covered

Current through Register Vol. 51, page 10, July 15, 2024
In addition to services not specifically listed as covered in §
									67:16:49:03 the following services
	 are not covered:
(1) Travel to
  services that do not meet the requirements of Article 67:16;
(2) Out of state travel not prior authorized
  by the department;
(3) Services
  that are duplicative of other covered services; and
(4) Costs associated with rescheduling travel
  due to a recipient initiated change in travel plans;
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:49 - NON-EMERGENCY MEDICAL TRAVEL SERVICES › Section 67:16:49:05 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
The rate of payment for travel covered under §
									67:16:49:03 is available on the
	 departments fee schedule website and limited to the following:
(1) Mileage outside the recipient's city of
  residence, which is limited to the actual miles between the two cities and does
  not include miles driven within the city. Only one mileage allowance is payable
  for each trip regardless of the number of recipients being transported. Mileage
  is a reimbursable service only if a trip is completed;
(2) Meals for the recipient. If an escort or
  volunteer driver is needed to transport the recipient, meals for the escort or
  volunteer driver are reimbursable. The department shall determine whether a
  meal is reimbursable based on the time of the scheduled appointment and the
  distance needed to be traveled;
(3)
  Lodging for the recipient. If a recipient is transporting himself or herself,
  the lodging reimbursement is limited to one payment per day. If an escort or
  volunteer driver is transporting his or her spouse or child who is a recipient,
  the lodging reimbursement is limited to one payment per day for the recipient
  and an additional payment is not allowed for the escort or volunteer driver. If
  the escort or volunteer driver is transporting someone other than his or her
  spouse or child, the escort or volunteer driver is allowed an additional
  payment per day for lodging expenses.
(4) The rate of payment for travel services
  provided by a commercial carrier is limited to the actual cost of the fare.
If the mode of travel chosen by the recipient is more expensive or if
	 the provider is more distant than is medically necessary, the department shall
	 pay the least costly method of travel suitable and available for travel to the
	 closest facility or medical provider available and capable of providing the
	 necessary service.
If the department determines that an individual is retroactively
	 eligible for medical assistance, payment for those documented expenses incurred
	 during the retroactive benefit period is subject to the limits in effect on the
	 date of the service.
The department shall reimburse the charitable organization the amount
	 advanced, not to exceed the limits established for each of the applicable
	 covered services. If the recipient, escort, or volunteer driver incurs travel
	 expenses that exceed the amount advanced by the charitable organization,
	 reimbursement for the additional expenses is limited to the maximum amount of
	 reimbursement established less the amount advanced by the charitable
	 organization.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:49 - NON-EMERGENCY MEDICAL TRAVEL SERVICES › Section 67:16:49:06 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for travel services provided under this chapter shall be
	 submitted on a form available from the department. The form shall contain 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) The name and address of the individual
  who is to receive payment for the travel services provided;
(4) If applicable, the name of the charitable
  organization that advanced funds and the amount advanced;
(5) The city of origin and the destination
  city;
(6) The departure date and
  the return date;
(7) The mode of
  transportation;
(8) The name of the
  medical facility to which the recipient is traveling and the doctor's name,
  national provider identification number, and specialty;
(9) The purpose of the visit; and
(10) The medical appointment date and time or
  if applicable, dates of hospitalization; If claiming lodging expenses, the
  receipt from the hotel must be attached to the claim. The claim must be signed
  and dated by the medical provider and the recipient, parent, or guardian.
A charitable organization may submit an invoice that contains the
	 above-referenced information instead of submitting the departments claim
	 form.
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 67:16:49 - NON-EMERGENCY MEDICAL TRAVEL SERVICES › Section 67:16:49:07 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for travel 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(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:49 - NON-EMERGENCY MEDICAL TRAVEL SERVICES › Section 67:16:49:08 - 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 medical travel assistance that exceeds the amount reimbursable
	 under this chapter to be an overpayment and subject to recovery. The department
	 may use a payment as an offset against an existing
	 overpayment.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(4)(6).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:49 - NON-EMERGENCY MEDICAL TRAVEL SERVICES › Section 67:16:49:09 - 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, 67:16:33, 67:16:34,
	 and 67:16:35.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(4)(6).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:17 - Office administration › Chapter 67:17:02 - Fair hearings › Section 67:17:02:01 - Right to hearing

Current through Register Vol. 51, page 10, July 15, 2024
An individual or entity that is aggrieved by the department's action or
	 inaction taken under the provisions of ARSD Title 67 may request a hearing. A
	 hearing is conducted under the provisions of this chapter and SDCL chapter
	 1-26. A hearing is not allowed if either state or federal law requires
	 automatic grant adjustments unless the reason for the hearing is an incorrect
	 computation.
General Authority:
SDCL
		28-1-24.1.
Law Implemented:
SDCL
		28-1-24.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:17 - Office administration › Chapter 67:17:02 - Fair hearings › Section 67:17:02:02 - Right to be informed of hearing process

Current through Register Vol. 51, page 10, July 15, 2024
The department shall inform each applicant and recipient of the right
	 to request a hearing. The department shall print this information on all
	 applications for public assistance and on all formal notices issued by the
	 department concerning an action taken.
General Authority:
SDCL
		28-1-24.1.
Law Implemented:
SDCL
		28-1-24.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:17 - Office administration › Chapter 67:17:02 - Fair hearings › Section 67:17:02:03 - Hearing requests

Current through Register Vol. 51, page 10, July 15, 2024
To appeal a department action or inaction made under the food stamp
	 program, the individual must clearly express to the department an intent to
	 appeal. The request for an appeal may be made either orally or in
	 writing.
For all other department programs, to appeal a department action or
	 inaction the individual or an individual representing the entity affected must
	 submit a written and signed request for a hearing to the Department of Social
	 Services, Office of Administrative Hearings. A person assisting an individual
	 such as a relative, friend, or attorney may request a hearing on the
	 individual's behalf.
When making a request for a hearing, the individual requesting the
	 appeal must indicate what department action is being appealed. If the reason
	 for the appeal is unclear, any party involved in the action may request the
	 Office of Administrative Hearings to further clarify the issue.
If the entity requesting a hearing is a corporation, the corporation
	 must be represented throughout the hearing process by its
	 attorney.
General Authority:
SDCL
		28-1-24.1.
Law Implemented:
SDCL
		28-1-24.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:17 - Office administration › Chapter 67:17:02 - Fair hearings › Section 67:17:02:11.01 - Hearings conducted by electronic means

Current through Register Vol. 51, page 10, July 15, 2024
The hearing examiner may hold a hearing by telephone conference or by
	 electronic or digital means.
For telephonic, electronic, or digital hearings, all parties must
	 submit their proposed exhibits to the hearing examiner and to the other parties
	 involved at least five calendar days before the hearing date.
General Authority:
SDCL
		28-1-24.1.
Law Implemented:
SDCL
		28-1-24.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:17 - Office administration › Chapter 67:17:02 - Fair hearings › Section 67:17:02:12 - Written notice of hearing

Current through Register Vol. 51, page 10, July 15, 2024
Unless waived by all parties, at least 10 days before the hearing the
	 department shall send a written notice of the hearing to the parties involved
	 in the action. In addition to the information required under SDCL
	 1-26-17, the notice shall contain
	 the following information:
(1) A
  statement that the parties must be present at the hearing with their
  witnesses;
(2) A statement that the
  parties must have all the exhibits and documents intended to be introduced into
  evidence;
(3) A statement that the
  parties have the right to request the hearing examiner to issue subpoenas for
  witnesses or documentary evidence;
(4) A statement that the parties may
  represent themselves, may be represented by an attorney, or may be assisted by
  another person such as a friend or relative;
(5) A statement that a corporation must be
  represented by its attorney;
(6) A
  statement that the department is not responsible for the appellant's legal
  fees; and
(7) A statement that the
  department is not responsible for the expenses of any individuals appearing on
  behalf of the appellant.
General Authority:
SDCL
		28-1-24.1.
Law Implemented:
SDCL
		28-1-24.1.
Default, §
											67:17:02:14.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:17 - Office administration › Chapter 67:17:02 - Fair hearings › Section 67:17:02:13 - Dismissal

Current through Register Vol. 51, page 10, July 15, 2024
The hearing examiner may dismiss an appeal under any of the following
	 circumstances:
(1) Except for appeals
  involving medical assistance, the appellant indicates in writing or verbally
  that the appellant wishes to withdraw the appeal;
(2) For appeals involving medical assistance,
  the appellant has submitted to the department a written request to withdraw the
  appeal;
(3) The appellant and the
  department resolve the case before the hearing examiner enters a final
  decision;
(4) The sole issue is one
  of state or federal law requiring automatic grant adjustments for classes of
  recipients; or
(5) The appellant is
  in default according to §
									67:17:02:14.
General Authority:
SDCL
		28-1-24.1.
Law Implemented:
SDCL
		28-1-24.1.
Informal resolution, §
											67:17:02:16.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:17 - Office administration › Chapter 67:17:02 - Fair hearings › Section 67:17:02:14 - Default

Current through Register Vol. 51, page 10, July 15, 2024
An appellant is considered to be in default if one of the following
	 circumstances exists:
(1) The
  appellant failed to appear at the hearing, did not request an exemption for
  appearing at the hearing at least 10 days before the hearing, and the Office of
  Administrative Hearings did not grant an exemption from this requirement before
  the hearing;
(2) The appellant
  fails to reply within 10 days to the hearing examiner's request to show good
  cause for the appellant's failure to appear at a hearing; or
(3) The hearing examiner finds that the
  reason the appellant failed to appear does not constitute good cause.
General Authority:
SDCL
		28-1-24.1.
Law Implemented:
SDCL
		28-1-24.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:17 - Office administration › Chapter 67:17:02 - Fair hearings › Section 67:17:02:16 - Informal resolution

Current through Register Vol. 51, page 10, July 15, 2024
Any time before a final decision is entered, the department may take
	 action to resolve the case. If the appellant is not represented by an attorney,
	 the department may contact the appellant directly. If the appellant is
	 represented by an attorney, department contact is limited to the appellant's
	 attorney. If the department resolves the case, the department must inform the
	 hearing examiner immediately.
General Authority:
SDCL
		28-1-24.1.
Law Implemented:
SDCL
		28-1-24.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:17 - Office administration › Chapter 67:17:02 - Fair hearings › Section 67:17:02:17 - Who may attend the hearing

Current through Register Vol. 51, page 10, July 15, 2024
Hearings may be attended only by the department and the appellant and
	 persons whom the appellant may wish to have represent or assist the appellant.
	 If the hearing involves a corporation, its attorney must represent the
	 corporation at the hearing.
General Authority:
SDCL
		28-1-24.1.
Law Implemented:
SDCL
		28-1-24.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:17 - Office administration › Chapter 67:17:02 - Fair hearings › Section 67:17:02:18 - Hearing examiner to arrange for recorded testimony

Current through Register Vol. 51, page 10, July 15, 2024
The hearing examiner shall arrange for the testimony to be recorded
	 under the hearing examiner's supervision. If no written transcript is prepared
	 and certified, the recording shall be kept for a minimum of 60 days after the
	 decision is served by mail.
General Authority:
SDCL
		28-1-24.1.
Law Implemented:
SDCL
		28-1-24.1.