South Dakota Administrative Code

Rule 67:16:02:03.01 Reimbursement for multiple surgeries. 67:16:02:03.01. Reimbursement for multiple surgeries. The department shall apply the provisions of this section and the fee schedules established under the provisions of § 67:16:02:01.01 to calculate the rate of reimbursem…

Rule 67:16:02:03.02 Reimbursement for services containing modifier codes. 67:16:02:03.02. Reimbursement for services containing modifier codes. Modifier codes which must be used if applicable are listed in § 67:16:02:03.03. When computing the rate of reimbursement, the department…

Rule 67:16:02:03.03 Required modifier codes. 67:16:02:03.03. Required modifier codes. A modifier code provides the means by which the reporting provider indicates on the claim form that a service or procedure performed was altered by some specific circumstance but not changed in …

Rule 67:16:02:04 Physician's services covered. 67:16:02:04. Physician's services covered. Physician's services covered are limited to the following professional services, which must be medically necessary and provided by a physician or other licensed practitioner to a recipient: …

Rule 67:16:02:05 Other health services covered. 67:16:02:05. Other health services covered. The other medically necessary health services and supplies covered under the program are limited to the following: (1) X rays for diagnostic and treatment purposes; (2) Laboratory tests fo…

Rule 67:16:02:05.01 Physical therapy services covered. 67:16:02:05.01. Physical therapy services covered. Physical therapy services which are ordered by a physician or other licensed practitioner through a written prescription and provided by a physical therapist licensed under S…

Rule 67:16:02:05.02 Repealed. 67:16:02:05.02. Breast reductions covered -- Prior authorization required. Repealed. Source: 16 SDR 64, effective October 8, 1989; 16 SDR 234, effective July 2, 1990; 28 SDR 166, effective June 12, 2002; repealed, 37 SDR 53, effective September 23, 2…

Rule 67:16:02:05.03 Repealed. 67:16:02:05.03. Clozaril therapy -- Limits.Repealed. Source: 18 SDR 50, effective September 15, 1991; repealed, 31 SDR 214, effective July 6, 2005.

Rule 67:16:02:05.04 Repealed. 67:16:02:05.04. Documentation required before authorization given. Repealed. Source: 18 SDR 50, effective September 15, 1991; 26 SDR 168, effective July 1, 2000; repealed, 31 SDR 214, effective July 6, 2005.

Rule 67:16:02:05.05 Repealed. 67:16:02:05.05. Requirements for monitoring clozaril therapy.Repealed. Source: 18 SDR 50, effective September 15, 1991; repealed, 31 SDR 214, effective July 6, 2005.

Rule 67:16:02:05.06 Repealed. 67:16:02:05.06. Requirements when clozaril therapy discontinued or suspended.Repealed. Source: 18 SDR 50, effective September 15, 1991; repealed, 31 SDR 214, effective July 6, 2005.

Rule 67:16:02:05.07 Repealed. 67:16:02:05.07. Requirements for augmentative communication device. Repealed Source: 19 SDR 26, effective August 23, 1992; repealed, 24 SDR 11, effective August 4, 1997.

Rule 67:16:02:05.08 Repealed. 67:16:02:05.08. Requirements for hyperbaric oxygen therapy. Repealed. Source: 20 SDR 144, effective March 10, 1994; 34 SDR 68, effective September 12, 2007; 42 SDR 51, effective October 13, 2015.

Rule 67:16:02:05.09 Repealed. 67:16:02:05.09. Prior authorization for hyperbaric oxygen therapy. Repealed. Source: 20 SDR 144, effective March 10, 1994; 42 SDR 51, effective October 13, 2015.

Rule 67:16:02:05.10 Repealed. 67:16:02:05.10. Breast reconstruction. Repealed. Source: 28 SDR 166, effective June 12, 2002; 42 SDR 51, effective October 13, 2015.

Rule 67:16:02:05.11 Repealed. 67:16:02:05.11. Noninvasive bone-growth stimulation. Repealed. Source: 28 SDR 166, effective June 12, 2002; 34 SDR 68, effective September 12, 2007; repealed, 37 SDR 53, effective September 23, 2010.

Rule 67:16:02:05.12 Repealed. 67:16:02:05.12. Cochlear implant -- Prior authorization required. Repealed. Source: 28 SDR 178, effective July 3, 2002; repealed, 40 SDR 122, effective January 7, 2014.

Rule 67:16:02:05.13 Repealed. 67:16:02:05.13. Hyperbaric oxygen therapy for individual with diabetes. Repealed. Source: 34 SDR 68, effective September 12, 2007; 42 SDR 51, effective October 13, 2015.

Rule 67:16:02:05.14 Repealed. 67:16:02:05.14. Hyperbaric oxygen therapy -- Individual with diabetes -- Course of standard wound care. Repealed. Source: 34 SDR 68, effective September 12, 2007; 42 SDR 51, effective October 13, 2015.

Rule 67:16:02:05.15 Occupational therapy. 67:16:02:05.15. Occupational therapy. Occupational therapy services are covered services if ordered by a physician or other licensed practitioner through a written prescription and provided by an occupational therapist licensed under SDCL…

67:16:02:06. Health services not covered. In addition to the services not specifically listed in § 67:16:02:05, the following health services and items are not covered under the medical assistance program: (1) Medical equipment for a resident in a nursing facility, an intermediat…

Rule 67:16:02:07 Utilization review for physician, laboratory, and X-ray services. 67:16:02:07. Utilization review for physician, laboratory, and X-ray services. Utilization review for physician, laboratory, and X-ray services may be provided on three levels: (1) Computerized cla…

Rule 67:16:02:08 Repealed. 67:16:02:08. Utilization review for transportation services. Repealed. Source: SL 1975, ch 16, § 1; 2 SDR 88, effective July 1, 1976; repealed, 7 SDR 23, effective September 18, 1980.

Rule 67:16:02:09 Sterilization. 67:16:02:09. Sterilization. Payment for sterilization is limited to those procedures performed on a recipient who meets the following criteria: (1) Is at least 21 years old; (2) Is a legally competent individual; (3) Has signed an informed consent …

Rule 67:16:02:10 Refractions and eyeglasses. 67:16:02:10. Refractions and eyeglasses. Payable physician services relating to refractions and the provision of eyeglasses are subject to the limits established in chapter 67:16:08. Source: SL 1975, ch 16, § 1; 2 SDR 88, effective Jul…

Rule 67:16:02:11 Repealed. 67:16:02:11. Cost sharing. Repealed. Source: 9 SDR 164, effective June 30, 1983; 10 SDR 79, effective February 1, 1984; 12 SDR 6, effective July 28, 1985; 31 SDR 191, effective June 8, 2005; 42 SDR 51, effective October 13, 2015.

Rule 67:16:02:12 Transferred. 67:16:02:12. Transferred to §§ 67:16:29:02 and 67:16:29:05.

Rule 67:16:02:13 Audiological and speech pathology services. 67:16:02:13. Audiological and speech pathology services. Payment may be made for audiological testing and speech-language pathology services if provided by a physician, a clinical audiologist licensed under SDCL chapter…

Rule 67:16:02:14 Reimbursement for services provided by nurse midwife or nurse anesthetist. 67:16:02:14. Reimbursement for services provided by nurse midwife or nurse anesthetist. Services provided by a nurse midwife or a nurse anesthetist are reimbursed at the rate for the same …

Rule 67:16:02:15 Reimbursement for services provided by nurse practitioner, clinical nurse specialist, or physician assistant. 67:16:02:15. Reimbursement for services provided by nurse practitioner, clinical nurse specialist, or physician assistant. Except for laboratory services…

Rule 67:16:02:16 Billing requirements -- Modifier codes -- Provider identification numbers. 67:16:02:16. Billing requirements -- Modifier codes -- Provider identification numbers. A claim submitted under this chapter must be submitted at the provider's usual and customary charge.…

Rule 67:16:02:16.01 Billing requirements -- Implantable contraceptive capsules and obstetrical services. 67:16:02:16.01. Billing requirements -- Implantable contraceptive capsules and obstetrical services. When computing the rate of reimbursement, the department uses the fee sche…

Rule 67:16:02:17 Claim requirements. 67:16:02:17. Claim requirements. A claim for services provided under this chapter must be submitted on a form or in an electronic format that contains the following information: (1) The recipient's full name; (2) The recipient's medical assist…

Rule 67:16:02:18 Repealed. 67:16:02:18. Certain services exempt from diagnosis code requirements. Repealed. Source: 17 SDR 4, effective July 16, 1990; 42 SDR 51, effective October 13, 2015; 43 SDR 80, effective December 5, 2016.

Rule 67:16:02:19 Application of other chapters. 67:16:02:19. Application of other chapters. In addition to the rules contained in this chapter, providers and recipients must meet the requirements of chapters 67:16:01, 67:16:26, 67:16:33, 67:16:34, 67:16:35, and 67:16:39. Source: …

Rule 67:16:03:01 Definitions. 67:16:03:01. Definitions. Terms used in this chapter mean: (1) "Benefit period," a period of days for which an individual may receive benefits for inpatient hospital services; (2) "Case mix index," the sum of the DRG weight factors for all Medicaid d…

Rule 67:16:03:01.01 Repealed. 67:16:03:01.01. Benefit period not to exceed 30 inpatient hospital days -- Determination of number of days. Repealed. Source: 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 9 SDR 111, effective February 27, 1983; …

Rule 67:16:03:01.02 Repealed. 67:16:03:01.02. Requirements for an outlier. Repealed. Source: 12 SDR 6, effective July 28, 1985; 15 SDR 2, effective July 17, 1988; repealed, 17 SDR 180, effective May 27, 1991.

Rule 67:16:03:01.03 Determination of emergency hospital care. 67:16:03:01.03. Determination of emergency hospital care. The physician or other licensed practitioner on duty or on call at a hospital shall determine whether the individual requires emergency hospital care. The need …

Rule 67:16:03:02 Inpatient hospital services covered. 67:16:03:02. Inpatient hospital services covered. The following inpatient hospital services covered under the medical assistance program are available to eligible individuals: (1) Semiprivate room accommodations and board. Pri…

Rule 67:16:03:02.01 Inpatient hospital services requiring prior authorization. 67:16:03:02.01. Inpatient hospital services requiring prior authorization. The attending physician, other licensed practitioner, representative of the physician or other licensed practitioner, or the h…

Rule 67:16:03:03 Outpatient hospital services covered. 67:16:03:03. Outpatient hospital services covered. The following outpatient hospital services covered under the medical assistance program are available to eligible individuals: (1) Laboratory services; (2) X ray and other ra…

Rule 67:16:03:04 Inpatient hospital services not covered. 67:16:03:04. Inpatient hospital services not covered. In addition to other services not specifically listed in § 67:16:03:02, the following inpatient hospital services are not covered under the medical assistance program: …

Rule 67:16:03:05 Repealed. 67:16:03:05. Outpatient hospital services not covered. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 13 SDR 8, effective August 3, 1986; 1…

Rule 67:16:03:06 Basis of reimbursement -- Inpatient services -- Hospitals with more than 30 Medicaid discharges. 67:16:03:06. Basis of reimbursement -- Inpatient services -- Hospitals with more than 30 Medicaid discharges. Reimbursement for services provided to a patient admitte…

Rule 67:16:03:06.01 Basis of reimbursement -- Outpatient services other than outpatient laboratory and outpatient surgical procedures. 67:16:03:06.01. Basis of reimbursement -- Outpatient services other than outpatient laboratory and outpatient surgical procedures. Reimbursement …

Rule 67:16:03:06.02 Certain in-state hospitals, hospital units, and procedures exempt from DRG basis of reimbursement. 67:16:03:06.02. Certain in-state hospitals, hospital units, and procedures exempt from DRG basis of reimbursement. In-state freestanding rehabilitation hospitals…

Rule 67:16:03:06.03 Basis of reimbursement -- Inpatient services -- Hospitals with less than 30 Medicaid discharges. 67:16:03:06.03. Basis of reimbursement -- Inpatient services -- Hospitals with less than 30 Medicaid discharges. Reimbursement for inpatient hospital services prov…

Rule 67:16:03:06.04 Basis of reimbursement -- Inpatient services -- Out-of-state hospitals. 67:16:03:06.04. Basis of reimbursement -- Inpatient services -- Out-of-state hospitals. The department shall reimburse out-of-state inpatient hospital services by making a prospective paym…

Rule 67:16:03:06.05 Repealed. 67:16:03:06.05. Basis of reimbursement -- Organ transplant procedures. Repealed. Source: 16 SDR 226, effective June 24, 1990; repealed, 18 SDR 198, effective June 3, 1992.