South Dakota Administrative Code

Rule 67:15:02:06 Time frame for payments to energy suppliers or landlords. 67:15:02:06. Time frame for payments to energy suppliers or landlords. The department shall make payments to participating energy suppliers or landlords in behalf of eligible households within 21 days afte…

Rule 67:15:02:07 Energy supplier to bill household for overages. 67:15:02:07. Energy supplier to bill household for overages. If the actual cost of home energy exceeds the payment made under LIEAP or ECIP, the energy supplier shall bill the household and collect the excess charge…

Rule 67:15:02:08 Utilization review. 67:15:02:08. Utilization review. The department shall conduct energy supplier and landlord utilization reviews to determine whether or not energy suppliers and landlords meet the requirements of the energy supply agreement and this article. So…

Rule 67:15:04:01 ECIP application. 67:15:04:01. ECIP application. An individual desiring ECIP assistance may apply by contacting the department's Office of Energy Assistance. Source: 8 SDR 95, effective February 18, 1982; 11 SDR 96, effective January 27, 1985; 17 SDR 66, effectiv…

Rule 67:15:04:02 Deadline for application. 67:15:04:02. Deadline for application. ECIP applications will be taken beginning the first working day in October and ending on March 31. Source: 8 SDR 95, effective February 18, 1982; 9 SDR 75, effective December 19, 1982; 10 SDR 30, ef…

Rule 67:15:04:03 ECIP funds available for emergencies. 67:15:04:03. ECIP funds available for emergencies. ECIP funds are available in an emergency to a LIEAP-eligible household that meets one of the following conditions: (1) For a household whose heat is included in the rent or w…

Rule 67:15:04:03.01 Income limits. 67:15:04:03.01. Income limits. To determine whether a household is income eligible for ECIP, the department shall compute the household's income according to § 67:15:01:10. Source: 13 SDR 64, effective December 4, 1986; 17 SDR 66, effective Nove…

Rule 67:15:04:04 Limits for ECIP payments. 67:15:04:04. Limits for ECIP payments. Maximum ECIP payment levels for the fuel or electricity used for a household's heating source shall be based on the ECIP income limits established in § 67:15:01:11. The maximum payments for the heat…

Rule 67:15:04:05 Notice to eligible households. 67:15:04:05. Notice to eligible households. If a household is determined to be eligible for ECIP assistance, the department shall notify the household of the amount of ECIP assistance for which the household is eligible. Notificatio…

Rule 67:15:04:06 Notice to ineligible households. 67:15:04:06. Notice to ineligible households. If a household is determined to be ineligible for ECIP assistance, the department shall inform the household of the reason for ineligibility within three working days after the date of…

Rule 67:15:04:07 Fair hearings. 67:15:04:07. Fair hearings. A request for a fair hearing shall be made within 60 days from the date of notice or inaction. Fair hearings shall be conducted according to chapter 67:17:02. Source: 8 SDR 95, effective February 18, 1982. General Author…

Rule 67:16:01:01 Definitions. 67:16:01:01. Definitions. Terms used in this article mean: (1) "Allowable costs," expenses incurred in meeting state licensure or federal certification standards for the provision of medical services; (2) "Applicant," an individual who has filed an a…

Rule 67:16:01:02 Transferred. 67:16:01:02. Transferred to § 67:46:01:02.

Rule 67:16:01:03 Repealed. 67:16:01:03. Eligibility starting date. Repealed. Source: SL 1975, ch 16, § 1; 2 SDR 88, effective July 1, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 26 SDR 168, effective July 1, 2000; repealed, 41 SDR 93, effective December 3, 2014.

Rule 67:16:01:04 Choosing a provider. 67:16:01:04. Choosing a provider. An eligible individual is free to choose a provider from among those willing to participate under the medical assistance program. If the eligible individual is required to participate in the primary care case…

Rule 67:16:01:05 Transferred. 67:16:01:05. Transferred to § 67:16:33:02.

Rule 67:16:01:06 Repealed. 67:16:01:06. Payment of Medicare buy-in premiums. Repealed. Source: SL 1975, ch 16, § 1; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 9 SDR 11, effective August 1, 1982; 17 SDR 4, effective July 16, 1990; 37 SDR 53, effective September 23, 2010; repealed…

Rule 67:16:01:06.01 Covered services. 67:16:01:06.01. Covered services. Covered services are those medically necessary health care services or items that are within the service limits and meet the prior authorization requirements specified in this article or article 67:54. The de…

Rule 67:16:01:06.02 Covered services must be medically necessary. 67:16:01:06.02. Covered services must be medically necessary. Services covered under this article must be medically necessary. To be medically necessary, the covered service must meet the following conditions: (1) …

Rule 67:16:01:06.03 Covered services requiring prior authorization. 67:16:01:06.03. Covered services requiring prior authorization. The department requires prior authorization for certain services. The provider shall obtain approval from the department before supplying services s…

Rule 67:16:01:07 State payment as payment in full -- Individual responsible for payment of noncovered services. 67:16:01:07. State payment as payment in full -- Individual responsible for payment of noncovered services. Payments under this article made on behalf of an eligible in…

Rule 67:16:01:07.01 Transferred. 67:16:01:07.01. Transferred to § 67:16:35:08.

Rule 67:16:01:07.02 Transferred. 67:16:01:07.02. Transferred to § 67:16:35:03.

67:16:01:08. Services not covered. In addition to items and services specified as not covered in other sections of this article, the following items and services are not covered under the medical assistance program: (1) Items or services which have been determined by the state de…

Rule 67:16:01:08.01 Sterilization services. 67:16:01:08.01. Sterilization services. Payment for sterilization services is limited to those services provided after the conditions contained in § 67:16:02:09 have been met. Source: 14 SDR 87, effective December 27, 1987. General Auth…

Rule 67:16:01:09 Amount of payment. 67:16:01:09. Amount of payment. The amount of payment for services under the medical assistance program shall not exceed the provider's usual and customary charge. Source: SL 1975, ch 16, § 1; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 17 SDR …

Rule 67:16:01:10 Payment of mileage to provider. 67:16:01:10. Payment of mileage to provider. A provider is not entitled to payment of mileage unless authorized under the provisions of chapter 67:16:25 or 67:16:49. Source: SL 1975, ch 16, § 1; 7 SDR 66, 7 SDR 89, effective July 1…

Rule 67:16:01:11 Payment made to provider. 67:16:01:11. Payment made to provider. Payments on behalf of an eligible individual shall be made directly to the provider. Source: SL 1975, ch 16, § 1; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 17 SDR 4, effective July 16, 1990. Gener…

Rule 67:16:01:12 Confidential information. 67:16:01:12. Confidential information. All information concerning applicants and recipients of medical assistance is limited to purposes directly connected with the administration of the medical assistance program and shall be treated as…

Rule 67:16:01:13 Identification card. 67:16:01:13. Identification card. The department shall issue an identification card to an individual eligible for medical services under this article. The individual must show this identification card to the medical provider when requesting s…

Rule 67:16:01:14 Transferred. 67:16:01:14. Transferred to § 67:16:35:04.

Rule 67:16:01:15 Repealed. 67:16:01:15. Other payments and private health insurance. Repealed. Source: SL 1975, ch 16, § 1; 7 SDR 66, 7 SDR 89, effective July 1, 1981; repealed, 16 SDR 226, effective June 24, 1990.

Rule 67:16:01:16 Uniformity of services. 67:16:01:16. Uniformity of services. The amount, duration, and scope of medical care and services available under the medical assistance program must be uniform for all eligible individuals, except the early and periodic screening, diagnos…

Rule 67:16:01:17 Fair hearings. 67:16:01:17. Fair hearings. Providers, applicants, and recipients shall be entitled to fair hearings in accordance with the provisions of SDCL 28-6-6 and chapter 67:17:02. Source: SL 1975, ch 16, § 1; 7 SDR 66, 7 SDR 89, effective July 1, 1981. Gen…

Rule 67:16:01:18 Civil rights. 67:16:01:18. Civil rights. A provider may not withhold services to any eligible individual because of race, color, creed, religion, sex, ancestry, handicap, political belief, marital or economic status, or national origin. A statement of compliance …

Rule 67:16:01:19 Utilization review. 67:16:01:19. Utilization review. Utilization review of services provided under the medical assistance program shall be conducted by the department. Source: 1 SDR 30, effective October 13, 1975; 7 SDR 66, 7 SDR 89, effective July 1, 1981. Gener…

Rule 67:16:01:20 Transferred. 67:16:01:20. Transferred to § 67:46:01:09.

Rule 67:16:01:21 Transferred. 67:16:01:21. Transferred to § 67:16:26:07.01.

67:16:01:22. Cost-sharing participants. Repealed. Source: 9 SDR 164, effective June 30, 1983; 11 SDR 86, effective December 30, 1984; 14 SDR 46, effective September 28, 1987; 16 SDR 114, effective January 15, 1990; 22 SDR 6, effective July 26, 1995; 22 SDR 32, effective September…

67:16:01:22.01. Services exempt from cost sharing. Repealed. Source: 42 SDR 51, effective October 13, 2015; 51 SDR 13, effective August 12, 2024.

67:16:01:23. Cost sharing deducted from allowable reimbursement before payment. Repealed. Source: 9 SDR 164, effective June 30, 1983; 51 SDR 13, effective August 12, 2024.

Rule 67:16:01:24 Application of chapter. 67:16:01:24. Application of chapter. The rules in this chapter apply to all enrolled providers and recipients. Source: 17 SDR 184, effective June 6, 1991. General Authority: SDCL 28-6-1. Law Implemented: SDCL 28-6-1.

67:16:01:25. Use of Current Procedural Terminology. The guidelines contained in CPT®2024: Current Procedural Terminology apply to claims submitted under the provisions of chapters 67:16:02, 67:16:03, 67:16:05, 67:16:07, 67:16:08, 67:16:09, 67:16:11, 67:16:12, 67:16:13, 67:16:24, …

67:16:01:26. Use of International Classification of Diseases. Claims submitted under the provisions of chapters 67:16:02, 67:16:03, 67:16:05, 67:16:07, 67:16:09, 67:16:11, 67:16:13, 67:16:25, 67:16:41, 67:16:43, 67:16:44, 67:16:46, 67:16:47, and 67:16:48 must contain the applicab…

67:16:01:27. Use of Health Care Common Procedure Coding System. The guidelines contained in the Health Care Common Procedure Coding System 2024 Level II apply to claims submitted under the provisions of chapters 67:16:02, 67:16:13, 67:16:28, 67:16:29, 67:16:44, 67:16:46, 67:16:47…

Rule 67:16:01:28 Use of HCPCS. 67:16:01:28. Rates and procedures subject to review and amendment -- Provider may request review. Rates paid under the provisions of article 67:16 and posted on the department's website located HERE are subject to review and amendment by the departm…

Rule 67:16:02:01 Definitions. 67:16:02:01. Definitions. Terms used in this chapter mean: (1) "Clinical nurse specialist," an individual who is licensed under SDCL 36-9-85 to perform the functions contained in SDCL 36-9-87, or an individual licensed or certified in another state t…

Rule 67:16:02:01.01 Fee schedules for physician services. 67:16:02:01.01. Fee schedules for physician services. Fee schedules for services provided under this chapter are available on the department's fee schedule website. When computing the rate of reimbursement for physician se…

Rule 67:16:02:02 Repealed. 67:16:02:02. Provider agreement. Repealed. Source: SL 1975, ch 16, § 1; repealed, 7 SDR 66, 7 SDR 89, effective July 1, 1981; cross-reference added, 16 SDR 234, effective July 2, 1990. Cross-Reference: Participating provider, § 67:16:33:02.

67:16:02:03. Rate of payment. When computing the rate of reimbursement, the department uses the fee schedules established under the provisions of § 67:16:02:01.01. A claim submitted under this chapter must be submitted at the provider's usual and customary charge. Payment is limi…