reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:03 - Individuals subject to care management

Current through Register Vol. 51, page 10, July 15, 2024
The following individuals are subject to care management:
(1) A recipient, including a recipient who
  has a third-party resource which may be liable for the recipient's medical
  expenses:
(2) An individual who has
  an SSI application pending;
(3) An
  individual who has an application for medical assistance pending; and
(4) A child born to an eligible
  recipient.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Eligibility requirements, §
											67:46:01:02; Third-party
		liability, ch 67:16:26.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:04 - Authorization for admission required

Current through Register Vol. 51, page 10, July 15, 2024
A hospital must receive authorization from the care manager before
	 admitting any of the individuals specified in §
									67:16:40:03 to one of the exempt
	 units listed in §
									67:16:40:02. The care manager
	 shall use the requirements established in §
									67:16:40:07,
	 67:16:40:08,
	 67:16:40:09, or 67:16:40:09.01 to
	 determine whether the individual should 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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:05 - Procedure for admission to psychiatric and neonatal units when care manager not available

Current through Register Vol. 51, page 10, July 15, 2024
If the admission is to a neonatal or psychiatric unit and the care
	 manager is not available, the hospital may use the criteria established in
	 §
									67:16:40:07 or
	 67:16:40:08 as a guideline to
	 determine whether to admit the individual. An admission made to a neonatal or
	 psychiatric unit when the care manager is not available is subject to
	 subsequent review and approval by the care manager.
If the care manager is not available and the individual is admitted,
	 the hospital must notify the care manager of the admission within the following
	 periods of time:
(1) If the individual
  admitted is a recipient, notification must be by the first working day after
  the date of admission;
(2) If the
  individual admitted has an application pending with either the medical
  assistance program or SSI, notification must be by the first working day after
  the hospital becomes aware the individual has an application pending;
  and
(3) If the individual obtains
  eligibility for the medical assistance program after admission, notification
  must be by the first working day after the hospital becomes aware of the
  individual's eligibility.
Failure to notify the care manager is cause for denial of the
	 claim.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:06 - Hospital to supply medical documentation to support admission

Current through Register Vol. 51, page 10, July 15, 2024
Before the care manager authorizes care under this chapter, the
	 hospital must provide the care manager with medical documentation which
	 substantiates that the admission is medically necessary and that the applicable
	 requirements of §
									67:16:40:07,
	 67:16:40:08,
	 67:16:40:09, or 67:16:40:09.01
	 were met.
If the care manager is not able to determine whether the admission,
	 continued stay, or discharge is justified, the care manager shall request a
	 care management consultant to review the documentation and make the
	 determination.
A care management consultant must review the documentation if the care
	 manager determines that the admission is not justified, a continued stay is not
	 warranted, or a patient should be discharged. The final decision as to the
	 admission, continued stay, or discharge rests with the care management
	 consultant. The care manager shall notify the hospital representative and the
	 attending physician of the final determination within one working day after the
	 final determination is made. The care manager may notify the hospital
	 representative orally but must follow the oral notice with a written
	 notice.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Covered services must be medically necessary, §
											67:16:01:06.02.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:07 - Admission requirements - Psychiatric care

Current through Register Vol. 51, page 10, July 15, 2024
An individual's psychiatric care is a covered service under this
	 chapter if the hospital received authorization for the admission under §
									67:16:40:04 and the following
	 conditions are met:
(1) A physician or
  other licensed practitioner completed a medical assessment of the individual
  and had at least a telephone consultation with a psychiatrist. The psychiatric
  consultation or diagnosis must include a treatable mental health condition. An
  admission is not allowed on the basis of a previous diagnosis if symptoms
  associated with the diagnosis are not active at the time of the
  admission;
(2) Outpatient services
  have failed or are not available in the community, or available services do not
  meet the treatment needs of the individual;
(3) Treatment of the individual's psychiatric
  condition requires services on an inpatient basis under the direction of a
  physician or other licensed practitioner, and there is an expectation that the
  individual will improve with psychiatric treatment of less than ten
  days;
(4) Inpatient services are
  expected to improve the individual's condition or prevent further regression so
  that the inpatient services will no longer be needed; and
(5) The individual meets one of the following
  criteria:
(a) Exhibits behavior which
  supports a reasonable expectation that the individual will inflict serious
  physical injury upon himself or others in the very near future, including a
  recently expressed threat which, if considered in light of its context or in
  light of the individual's recent previous acts, is substantially supportive of
  an expectation that the threat will be carried out;
(b) Exhibits psychotic behavior with
  hallucinations or delusions;
(c) Is
  admitted under the provisions of SDCL
  27A-10-1 and
  27A-10-2 for a 24-hour hold for
  an evaluation; or
(d) Experiences
  reactions or intolerances to medications which cannot be managed in an
  outpatient or medical floor setting.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:08 - Admission requirements - Neonatal intensive care

Current through Register Vol. 51, page 10, July 15, 2024
Neonatal intensive care services are considered covered services if a
	 neonatologist orders the admission, there is a comprehensive history and
	 physical that addresses the need for the admission, the condition requires
	 continuous cardiopulmonary monitoring, the condition requires monitoring of
	 complete vital signs at a minimum of once every four hours, and the infant has
	 at least one of the following conditions:
(1) Abnormal vital signs, hematology, or
  chemistry to cause endangerment;
(2) Congenital abnormalities causing
  functional impairment;
(3)
  Pulmonary distress;
(4) Metabolic
  distress;
(5) Cardiac
  distress;
(6) Neurological
  distress;
(7) Gastrointestinal
  abnormalities;
(8)
  Sepsis;
(9) Prematurity of
  significant intrauterine growth retardation; or
(10) Any condition which requires surgery
  within 48 hours after birth.
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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:09 - Admission requirements - Rehabilitation care

Current through Register Vol. 51, page 10, July 15, 2024
An individual's admission to a rehabilitation unit is a covered service
	 if the hospital received authorization for the admission under §
									67:16:40:04 and the care manager
	 determines that the following criteria are met:
(1) The individual's previous medical
  condition was functional;
(2) The
  individual is capable of weekly improvement in the activities of daily
  living;
(3) The individual's
  primary medical condition is stable; and
(4) The individual is able to participate in
  rehabilitation therapies and can demonstrate gains in functional
  abilities.
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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:09.01 - Admission requirements - Long-term care hospital unit

Current through Register Vol. 51, page 10, July 15, 2024
Admissions to a long-term care hospital unit are limited to transfers
	 from a general acute care hospital and must be more cost effective than if the
	 entire length of stay had been in the general, acute care hospital.
An individual's admission to a long-term care hospital unit is a
	 covered service if the hospital received authorization for the admission under
	 §
									67:16:40:04 and the care manager
	 determines that the following requirements are met:
(1) The individual is medically
  stable;
(2) The individual has
  potential for functional gains within two weeks;
(3) The individual is able to participate in
  rehabilitation therapies and can demonstrate gains in functional
  abilities;
(4) The medical
  complications cause a significant decline in physical function; and
(5) There is no alternative course of
  treatment setting available for the recipient requesting the service which is
  more conservative or substantially less costly.
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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:10 - Care plan requirements

Current through Register Vol. 51, page 10, July 15, 2024
A facility must prepare a care plan for each individual 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
  individual;
(2) The frequency and
  duration of the needed services; and
(3) The estimated length of stay.
The facility must prepare the care plan and submit it to the care
	 manager within 24 hours after the individual 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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:11 - Psychiatric admission requires psychiatric evaluation

Current through Register Vol. 51, page 10, July 15, 2024
Within 24 hours after an individual is admitted for inpatient
	 psychiatric care, the hospital must have a psychiatrist complete a psychiatric
	 evaluation of the individual. The evaluation must be included in the
	 individual's medical record.
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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:12 - Hospital to supply information to care manager

Current through Register Vol. 51, page 10, July 15, 2024
Within 24 hours after the care manager's request, a facility must
	 provide or make available the active or closed admission records of those
	 individuals subject to care management.
Records include the individual's complete medical history, the progress
	 notes, results from laboratory tests and X rays, and any other documentation
	 which may be necessary to determine the medical necessity of an individual's
	 admission or continued stay.
The facility must inform the care manager of planned care conferences
	 and allow the care manager to attend the conferences. The care manager may use
	 the information received at the conference when determining the medical
	 necessity for an individual's admission to or continued stay in the
	 facility.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(4).
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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:13 - 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 individual's medical records to determine whether the individual's
	 condition justifies continued care 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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:14 - Requirements for continued stay - Psychiatric care

Current through Register Vol. 51, page 10, July 15, 2024
An individual's continuous and uninterrupted stay in inpatient
	 psychiatric care is a covered service if the care manager determines that the
	 following criteria are met:
(1) The
  individual continues to be a danger to self or others and is not able to
  function or utilize outpatient care, as reflected in the medical
  record;
(2) The individual is
  complying with the recommendations made through the care conferences;
  and
(3) The individual's daily
  progress notes show improvement towards the goal of discharge.
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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:15 - Requirements for continued stay - Rehabilitation care

Current through Register Vol. 51, page 10, July 15, 2024
An individual's continued stay in a rehabilitation unit is a covered
	 service under this chapter if the individual demonstrates weekly improvement in
	 becoming independent in the activities of daily living and is complying with
	 the recommendations made through the care conference.
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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:16 - Requirements for continued stay - Neonatal intensive care

Current through Register Vol. 51, page 10, July 15, 2024
Continued stay in a neonatal intensive care unit is a medically
	 necessary covered service only if at least one of the conditions specified in
	 §
									67:16:40:08 continues to
	 exist.
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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:16.01 - Requirements for continued stay - Long-term care hospital unit

Current through Register Vol. 51, page 10, July 15, 2024
An individual's continued stay in a long-term care hospital unit is a
	 covered service under this chapter if the individual has demonstrated continued
	 functional gains for a period of two weeks and the individual continues to
	 require care that cannot be provided in a rehabilitation unit, nursing home, or
	 in the individual's own home.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:17 - Criteria for terminating coverage - Psychiatric care

Current through Register Vol. 51, page 10, July 15, 2024
An individual's psychiatric care becomes a noncovered service when the
	 care manager determines that the conditions of §
									67:16:40:07 are no longer
	 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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:18 - Criteria for terminating coverage - Rehabilitation

Current through Register Vol. 51, page 10, July 15, 2024
An individual's care in a rehabilitation unit becomes a noncovered
	 service if the care manager determines that the individual meets any of the
	 following criteria:
(1) The individual
  has reached potential in the current setting;
(2) The individual is functional;
(3) The individual's condition is stable to
  the point of receiving outpatient care or care in an alternative setting;
  or
(4) The individual is not
  complying with the recommendations made through the care conference.
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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:19 - Criteria for terminating coverage - Neonatal intensive care

Current through Register Vol. 51, page 10, July 15, 2024
An infant's care in a neonatal intensive care unit becomes a noncovered
	 service if the infant meets all of the following criteria:
(1) Vital signs and medical conditions,
  including apnea and bradycardia, are stable or resolved and the infant no
  longer requires intensive care;
(2)
  The newborn could go home or to another hospital unit; and
(3) The newborn is being nourished and has
  consistent weight and growth.
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 67:16:40 - Care management - Rehabilitation, psychiatric, neonatal › Section 67:16:40:20 - Criteria for terminating coverage - Long-term care hospital unit

Current through Register Vol. 51, page 10, July 15, 2024
An individual's care in a long-term care hospital unit becomes a
	 noncovered service if the care manager determines that the individual meets any
	 of the following criteria:
(1) The
  individual no long requires care in a long-term care hospital unit;
(2) The individual meets the requirements for
  admission to a rehabilitation unit as specified in §
									67:16:40:09;
(3) The individual meets the requirements for
  admission to a nursing home as specified in chapter 67:45:01; or
(4) The individual has not demonstrated
  continued functional gains for two weeks.
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 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:02 - Mental health service requirements

Current through Register Vol. 51, page 10, July 15, 2024
To be covered under this chapter, mental health services are limited to
	 services established in this chapter which meet all of the following
	 requirements:
(1) The mental health
  provider has prepared a diagnostic assessment according to §
									67:16:41:04;
(2) The diagnostic assessment contains a
  primary diagnosis of one of the mental disorders specified in §
									67:16:41:05;
(3) The mental health provider has prepared
  an individual treatment plan which meets the requirements of §§
									67:16:41:06 and
  67:16:41:07;
(4) The mental health provider provides
  treatment directly to the recipient or via collateral contact;
(5) The treatment is documented in the
  recipient's clinical record according to §
									67:16:41:08; and
(6) The treatment is medically necessary
  according to §
									67:16:01:06.02.
Failure to meet all of the above requirements is cause for the
	 department to determine the mental health services to be noncovered
	 services.
Mental health services may be provided to a recipient during the
	 30-day time period the mental health provider has to complete the diagnostic
	 assessment, if the mental health provider has met the above requirements and
	 has made a provisional diagnosis of a mental health disorder
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 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:03 - Mental health provider

Current through Register Vol. 51, page 10, July 15, 2024
A mental health provider must be a psychologist, a licensed
	 professional counselor - mental health, a licensed professional counselor
	 working toward a mental health designation, a clinical nurse specialist, a
	 certified social worker-PIP, a certified social worker - PIP candidate, or a
	 licensed marriage and family therapist who has a signed provider agreement with
	 the department to provide mental health services.
A mental health provider must have a National Provider Identification
	 (NPI) number and may not provide services under another provider's medical
	 assistance provider NPI number.
An individual who does not meet the certification or licensure
	 requirements of the applicable profession may not enroll as a mental health
	 provider or participate in the delivery of mental health
	 services.
General Authority:
SDCL
		28-6-1(1)(2)(4).
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
Provider requirements, ch
		67:16:33.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:04 - Diagnostic assessment requirements

Current through Register Vol. 51, page 10, July 15, 2024
(1) A diagnostic assessment must be completed
  within 30 days of the recipient's first face-to-face or telehealth visit with a
  mental health provider. On-going assessment and identification of changes in
  the recipient's needs and strengths must occur throughout treatment and must be
  documented in progress notes or other clinical documentation. Three
  face-to-face or telehealth interviews designed to assist in the formulation of
  a diagnostic assessment are covered. For children under 18 years of age, the
  mental health staff shall obtain permission from the parent or legal guardian
  to meet with the child, and at least one parent or legal guardian shall
  participate in the assessment. Psychiatric therapeutic procedures or
  psychiatric somatotherapy provided before the diagnostic assessment is
  completed are considered noncovered services.
(2) A diagnostic assessment must include all
  of the following components:
(a) A
  face-to-face or telehealth interview with the recipient;
(b) Identification of the strengths of the
  recipient and the recipient's family, if appropriate, previous periods of
  success and the strengths that contributed to that success, and potential
  resources within the family, if applicable;
(c) Presenting problems or issues that
  indicate a need for mental health services;
(d) Identification of readiness for change
  for problem areas, including motivation and supports for making such
  changes;
(e) Relevant family
  history, including family relationship dynamics and family psychiatric and
  substance abuse history;
(f)
  Behavioral observations and an examination of the recipient's mental status,
  including a description of anomalies in the recipient's appearance, general
  behavior, motor activity, speech, alertness, mood, cognitive functioning, and
  attitude toward the symptoms;
(g)
  Current substance use and relevant treatment history, including attention to
  previous mental health and substance use disorder or gambling treatment and
  periods of success, psychiatric hospital admissions, psychotropic and other
  medications, relapse history or potential for relapse, physical illness, and
  hospitalization;
(h) A review of
  the records that pertain to the recipient's medical and social background and
  history, if available;
(i) Contact
  with the recipient's relatives and significant others to the extent necessary
  to complete an accurate psychological evaluation for the purpose of writing the
  assessment report and developing the treatment plan; and
(j) Formulation of a diagnosis that is
  consistent with the findings of the evaluation of the recipient's condition,
  including documentation of co-occurring medical, developmental disability,
  mental health, substance use disorder or gambling issues, or a combination of
  these based on the diagnostic evaluation.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:05 - Mental disorder diagnosis codes - Limits

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of this chapter, mental disorder diagnosis codes are
	 limited to the diagnosis codes listed on the departments billing guidance
	 website and contained in the ICD-10-CM adopted in §
									67:16:01:26.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:06 - Treatment plan requirements

Current through Register Vol. 51, page 10, July 15, 2024
The mental health provider must develop a treatment plan for each
	 recipient who is receiving medically-necessary, covered mental health treatment
	 based on a primary diagnosis of a mental disorder. The plan must be relevant to
	 the diagnosis, be developmentally appropriate, and relate to each covered
	 mental health treatment to be delivered. Evidence of participation by the
	 recipient or the recipient's legal guardian and evidence of meaningful
	 involvement in formulating the plan must be documented in the file.
The treatment plan must:
(1)
  Be developed jointly by the recipient, or the recipient's legal guardian, and
  the mental health provider who will be providing the covered mental health
  treatment;
(2) Be understandable by
  the recipient and the recipient's legal guardian, if applicable;
(3) Include a list of other professionals
  known to be involved in the case;
(4) Contain written goals, objectives, or
  both, which are individualized, clear, specific, and measurable so that the
  recipient and the mental health provider can determine if progress has been
  made, and which specifically address the recipient's treatment goals;
(5) Be based on the findings of the
  diagnostic assessment and contain the recipient's mental disorder diagnosis
  code;
(6) List the specific
  therapies, interventions, and activities that match the recipient's readiness
  for change for identified issues, and which are prescribed for meeting the
  treatment goals;
(7) Include the
  specific treatment goals for improving the recipient's condition to a point of
  no longer needing mental health treatment; and
(8) Include a specific schedule of treatment
  services including the prescribed frequency and duration of each mental health
  service to be provided to meet the treatment plan goals.
The mental health provider must complete, sign, and date the treatment
	 plan within thirty days of intake. The signature is a certification by the
	 mental health provider that the treatment plan is accurate. The certification
	 date is the effective date of the treatment plan. A copy of the treatment plan
	 must be provided to the recipient and to the recipient's parent or guardian, if
	 applicable.
Mental health treatment provided after the third session with the
	 recipient, without a supporting treatment plan meeting the requirements of this
	 section, is not covered.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Clinical record requirements, §
											67:16:41:08.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:07 - Treatment plan reviews

Current through Register Vol. 51, page 10, July 15, 2024
As long as mental health services continue, the mental health provider
	 must review the recipient's treatment plan at least semiannually with the first
	 review completed no later than six months from the effective date of the
	 initial treatment plan. Each semiannual review must contain a written review of
	 the progress made toward the established treatment goals, significant changes
	 to the treatment goals, and a justification for continued mental health
	 services. When there is a significant change in the recipient's treatment
	 goals, the mental health provider must review the treatment plan and record the
	 changes in the treatment plan.
The mental health provider who conducted the review and prepared the
	 written documentation must sign and date the documentation.
Covered mental health services provided without the required semiannual
	 treatment plan review or without significant changes added into the treatment
	 plan, as required in this section, are considered noncovered
	 services.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Clinical record requirements, §
											67:16:41:08.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:08 - Clinical record requirements

Current through Register Vol. 51, page 10, July 15, 2024
The mental health provider must maintain the recipient's clinical
	 record. In addition to the record requirements contained in chapter 67:16:34,
	 the recipient's clinical record must contain all of the following information,
	 including the related supporting clinical data:
(1) Concise data on client history, including
  present illness and complaints, past history (psychological, social, and
  medical), previous hospitalization and treatment, and a drug-use
  profile;
(2) A diagnostic
  assessment which meets the requirements of §
									67:16:41:04;
(3) A treatment plan which meets the
  requirements of §
									67:16:41:06;
(4) A chronological record of known
  psychotropic medications prescribed and dispensed;
(5) Documentation of treatment plan reviews
  required in §
									67:16:41:07;
(6) The specific services provided together
  with the date and amount of time of delivery of each service
  provided;
(7) The signature or
  initials and credential of the mental health provider providing the
  service;
(8) The location of the
  setting in which the service was provided;
(9) The relationship of the service to the
  treatment plan objectives and goals;
(10) Progress or treatment notes, entered
  chronologically at each encounter of service, documenting and summarizing
  progress the recipient is making during a given period of time toward attaining
  the treatment objectives and goals; an assessment of the recipient's current
  symptoms; a report of procedures administered during the session; and a plan
  for the next treatment session; and
(11) When the treatment is complete or
  discontinued, a discharge summary which relates to the treatment received and
  progress made in achieving the treatment goals. A discharge summary is not
  required when the recipient prematurely discontinues the treatment.
All entries within the required clinical record must be current,
	 consistently organized, legible, signed or initialed, and dated by the mental
	 health 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 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:09 - Covered mental health services - Limits - Payments

Current through Register Vol. 51, page 10, July 15, 2024
Payment for mental health services is the lesser of the provider's
	 usual and customary charge or the fee listed on the department's fee schedule
	 website. If no fee is listed, payment is 40 percent of the provider's usual and
	 customary charge.
Mental health services and associated rates of payment are subject to
	 review and amendment under §
									67:16:01:28.
Payment for psychiatric therapeutic procedures is limited to those
	 recipients who have been determined to have a primary diagnosis of a mental
	 disorder or a provisional diagnosis of a mental health disorder during the
	 30-day time period that the mental health provider has to complete the
	 diagnostic assessment.
Time units are for face-to-face or telehealth session times with the
	 recipient or collateral contact and do not include time used for traveling,
	 reporting, charting, or other administrative functions outside the scope of
	 covered procedure codes.
The maximum allowable coverage for all psychotherapy services may not
	 exceed 40 hours of therapy in a 12-month period unless prior authorized by the
	 department. For purposes of this limit, procedure codes without an associated
	 time will be considered one hour.
General Authority:
SDCL
		28-6-1(1)(2)(4).
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 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:10 - Noncovered services

Current through Register Vol. 51, page 10, July 15, 2024
The department does not cover and the provider may not submit a claim
	 for:
(1) Mental health services not
  defined in §
									67:16:41:01;
(2) Mental health treatment provided without
  the recipient physically present in a face-to-face session with the mental
  health provider, except for telehealth treatment and collateral
  contact;
(3) Treatment for a mental
  health disorder not included in the diagnosis codes set forth in §
									67:16:41:05;
(4) Mental health treatment provided before a
  diagnostic assessment is completed, except treatment provided with a
  provisional diagnosis of a mental health disorder during the thirty day time
  period the mental health provider has to complete the diagnostic
  assessment;
(5) Mental health
  treatment provided after thirty days of intake, if a treatment plan has not
  been completed;
(6) Mental health
  treatment provided if a required treatment plan review has not been
  completed;
(7) Court appearance,
  staffing sessions, or treatment team appearances;
(8) Mental health services provided to a
  recipient incarcerated in a correctional facility;
(9) Mental health services provided to a
  recipient in an institution for mental diseases or an intermediate care
  facility for individuals with intellectual disabilities;
(10) Mental health treatment provided, if the
  treatment does not demonstrate a reasonably-timed continuum of progress toward
  the specific goals stated in the treatment plan, as determined by the peer
  review entity;
(11) Mental health
  treatment provided, if the treatment is not listed in the treatment plan or
  documented in the recipient's clinical record, even though the service is
  allowable under this chapter;
(12)
  Mental health treatment provided to a recipient who is:
(a) Incapable of cognitive functioning due to
  age or mental incapacity; or
(b)
  Unable to receive any benefit from the service;
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:11 - Prior authorization

Current through Register Vol. 51, page 10, July 15, 2024
A mental health provider must have prior authorization from the
	 department before providing any treatment listed in §
									67:16:41:09 which will exceed the
	 limits established in this chapter. Authorization is based on documentation
	 submitted to the department by the mental health provider. The documentation
	 must include the provider's written treatment plan, the diagnosis, and the
	 planned treatment. Failure to obtain approval from the department before
	 providing the service is cause for the department to determine that the service
	 is a noncovered service.
The department may verbally authorize treatment; however, the
	 department must verify a verbal authorization in writing before the services
	 are paid.
Treatment which exceeds the established limits is subject to peer
	 reviews according to §
									67:16:41:15.
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 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:12

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 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:13 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for services provided under this chapter must be submitted on
	 a form which contains the following information:
(1) The recipient's full name;
(2) The recipient's medical assistance
  identification number from the recipient's medical 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 from
  this charge;
(7) Units of service
  furnished, if more than one;
(8)
  The applicable procedure codes contained in §
									67:16:41:09;
(9) The applicable diagnosis codes adopted in
  §
									67:16:01:26;
(10) The provider's name and National
  Provider Identification (NPI) number; and
(11) Type of service provided.
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 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:14 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
The following apply to services billed under this chapter:
(1) A provider may not submit a claim under
  another provider's identification number. A claim must contain the medical
  assistance provider identification number of the individual delivering the
  service;
(2) A provider may not
  submit a claim for a diagnostic assessment that exceeds four hours, unless
  there has been a break of at least 12 months in the delivery of mental health
  treatment to the recipient;
(3) A
  provider may not submit a claim for a diagnostic assessment until the
  assessment is completed and recorded in the recipient's clinical
  record;
(4) A provider may not
  submit a claim for mental health treatment provided before the diagnostic
  assessment is completed, except for treatment provided with a provisional
  diagnosis of a mental health disorder during the 30-day time period the mental
  health provider has to complete the diagnostic assessment;
(5) A provider may not submit a claim for
  mental health services provided after the fourth face-to-face or telehealth
  session with the recipient and before the effective date of the treatment
  plan;
(6) If a psychotherapy
  session is provided to more than one individual, the service must be billed as
  family or group psychotherapy, whichever is appropriate, even if the individual
  is the only one eligible for the medical assistance program;
(7) If a recipient is involved in a
  psychotherapy session only as part of a family or group session for treatment
  of another family member who is a mental health client, a provider may not
  submit a claim for the recipient for that session;
(8) Except for a psychiatric diagnostic
  interview examination and a diagnostic assessment, a provider may not submit a
  claim for mental health treatment if the recipient does not have a primary
  diagnosis of a mental disorder; and
(9) A provider may submit a claim for each
  eligible recipient who is in a family or group psychotherapy session and is
  actively receiving psychotherapy, if each family or group member for whom
  services are billed to the medical assistance program has a complete clinical
  record that meets the requirements of §
									67:16:41:08.
The provider must submit claims at the provider's usual and customary
	 charge and the claim may contain only those procedure codes listed on the
	 department's fee schedule website.
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 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:15 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review may be conducted on the following levels:
(1) Computerized claim processing;
(2) Postpayment review; and
(3) Peer review.
A peer review entity appointed by the department shall review claims to
	 determine and ensure the appropriate quality, quantity, and medical necessity
	 of mental health services provided.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:16

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 67:16:41 - Mental health services by independent practitioners › Section 67:16:41:17 - 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 › Section 67:16:42:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Enteral nutritional therapy,"
  nutritional therapy by way of the small intestine through nasogastric,
  jejunostomy, or gastrostomy tubes;
(2) "Nutritional supplement," specialized
  formulas required to increase a child's daily protein and caloric
  intake;
(3) "Nutritional therapy,"
  specialized formulas or hyperalimentation which serves as the sole means of
  nutrition and is required when nutrition cannot be sustained through oral
  feedings due to a chronic illness or trauma; and
(4) "Parenteral nutritional therapy,"
  nutritional therapy by intravenous injection.
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 67:16:42:02

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:03

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 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:04

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:05

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:06

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:42 - Nutritional therapy and nutritional supplements › Section 67:16:42:07 - Nutritional therapy and nutritional supplements - Limits

Current through Register Vol. 51, page 10, July 15, 2024
Covered enteral therapy, oral nutrition, electrolyte replacement, and
	 parenteral therapy services and supplies are contained on the department's fee
	 schedule website.
The therapy services and their associated rates of payment are subject
	 to review and amendment under the provisions of §
									67:16:01:28.
Enteral therapy for individuals age 21 and older and parenteral therapy
	 must have prior approval from the department.
Equipment necessary to administer the parenteral or enteral nutritional
	 therapy are covered under the provisions of chapter 67:16:29.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1,
		28-6-1.1.