South Dakota Administrative Code

Rule 67:16:03:06.06 Reimbursement for in-state DRG-exempt hospitals and units. 67:16:03:06.06. Reimbursement for in-state DRG-exempt hospitals and units. Reimbursement to in-state DRG-exempt hospitals and units is based on reasonable and allowable costs following guidelines estab…

Rule 67:16:03:06.07 Reimbursement of outpatient laboratory services. 67:16:03:06.07. Reimbursement of outpatient laboratory services. Except for Medicare prospective payment system hospitals, outpatient laboratory services are reimbursed according to the outpatient laboratory fee…

Rule 67:16:03:06.08 Payment for above-average, access-critical and above-average, at-risk hospitals. 67:16:03:06.08. Payment for above-average, access-critical and above-average, at-risk hospitals. If the Department of Health determines that a hospital is an above-average, access…

Rule 67:16:03:06.09 Disproportionate share hospitals. 67:16:03:06.09. Disproportionate share hospitals. To qualify as a disproportionate share hospital, the hospital must meet all of the following requirements: (1) Have a Medicaid inpatient utilization rate that is above the mean…

Rule 67:16:03:06.10 Classification of hospitals providing certain outpatient surgical procedures. 67:16:03:06.10. Classification of hospitals providing certain outpatient surgical procedures. Except for Medicare prospective payment system hospitals, if a hospital provides any of …

Rule 67:16:03:06.11 Basis of reimbursement -- Outpatient surgical procedures covered under subdivision 67:16:03:03(10). 67:16:03:06.11. Basis of reimbursement -- Outpatient surgical procedures covered under subdivision 67:16:03:03(10). Reimbursement for an outpatient surgical pro…

Rule 67:16:03:06.12 Services included in reimbursement rate for outpatient surgical procedures covered under to chapter 67:16:28. 67:16:03:06.12. Services included in reimbursement rate for outpatient surgical procedures covered under chapter 67:16:28. For those outpatient surgic…

Rule 67:16:03:06.13 Items and services not included in reimbursement rate for outpatient surgical services covered under chapter 67:16:28 and paid under the provisions of chapter 67:16:03. 67:16:03:06.13. Items and services not included in reimbursement rate for outpatient surgic…

Rule 67:16:03:06.14 Payment groups for outpatient hospital surgical procedures covered under chapter 67:16:28. 67:16:03:06.14. Payment groups for outpatient hospital surgical procedures covered under chapter 67:16:28. The payments assigned to the different groups of outpatient ho…

Rule 67:16:03:06.15 Rate of payment -- Medicare crossover claims for certain inpatient hospital services. 67:16:03:06.15. Rate of payment -- Medicare crossover claims for certain inpatient hospital services. If the department receives a Medicare crossover claim for an inpatient h…

Rule 67:16:03:06.16 Rate of reimbursement if individual subject to care management remains in psychiatric unit beyond established discharge date. 67:16:03:06.16. Rate of reimbursement if individual subject to care management remains in psychiatric unit beyond established discharg…

Rule 67:16:03:06.17 Basis of reimbursement -- Inpatient services -- claims containing revenue code 2750r 278. 67:16:03:06.17. Basis of reimbursement – Inpatient services – Claims containing revenue code 275 or 278. Claims submitted for inpatient hospital services by an in-state a…

Rule 67:16:03:06.18 Basis of Reimbursement -- OPPS. 67:16:03:06.18. Basis of Reimbursement -- OPPS. Medicare prospective payment system hospitals shall be paid using the Department's OPPS. Under OPPS, services are reimbursed using ambulatory payment classifications. The Departmen…

Rule 67:16:03:07 Payment of hospital services. 67:16:03:07. Payment of hospital services. Payments to hospitals for services provided to eligible individuals shall be made for medically necessary services provided on an inpatient or outpatient basis and for deductibles and coinsu…

Rule 67:16:03:07.01 Maximum rate of payment -- Transfers between DRG reimbursed hospital unit and DRG-exempt intensive care nursery unit in same hospital. 67:16:03:07.01. Maximum rate of payment -- Transfers between DRG-reimbursed hospital unit and DRG-exempt intensive care nurse…

Rule 67:16:03:07.02 Maximum rate of payment -- Patient transfer not medically necessary. 67:16:03:07.02. Maximum rate of payment -- Patient transfer not medically necessary. If a patient is transferred between hospitals and the transfer is not medically necessary, the total reimb…

Rule 67:16:03:08 Repealed. 67:16:03:08. Notification of hospital services. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; repealed, 7 SDR 23, effective September 18, 1980.

Rule 67:16:03:09 Repealed. 67:16:03:09. Verification of eligibility. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; repealed, 7 SDR 23, effective September 18, 1980.

Rule 67:16:03:10 Utilization review. 67:16:03:10. Utilization review. The department may review inpatient hospital service claims for the following information: (1) Necessity of admission; (2) Length of stay; (3) Coding; (4) Computerized claims processing; (5) Post-payment review…

Rule 67:16:03:11 Inpatient psychiatric hospital services. 67:16:03:11. Inpatient psychiatric hospital services. Services provided by freestanding psychiatric hospitals are not payable. Source: 9 SDR 11, effective August 1, 1982; 12 SDR 70, effective October 31, 1985; repealed, 15…

Rule 67:16:03:12 Transferred. 67:16:03:12. Transferred to § 67:16:03:06.

Rule 67:16:03:13 Repealed. 67:16:03:13. Cost sharing. Repealed. Source: 9 SDR 164, effective June 30, 1983; 12 SDR 70, effective October 31, 1985. 23 SDR 232, effective July 10, 1997; 26 SDR 157, effective June 7, 2000; 31 SDR 191, effective June 8, 2005; 42 SDR 51, effective Oct…

67:16:03:14. Claim requirements. A claim for services provided under this chapter must be submitted at the hospital's usual and customary charge to the general public and must comply with the informational requirements established in the Official UB-04 Data Specifications Manual …

Rule 67:16:03:14.01 Billing requirements. 67:16:03:14.01. Billing requirements. A claim submitted under this chapter must be submitted at the provider's usual and customary charge. For an outpatient laboratory test, the laboratory which actually performed the test must submit the…

Rule 67:16:03:14.02 Claim requirements for individuals subject to managed care who remain in psychiatric unit beyond established discharge date. 67:16:03:14.02. Claim requirements for individuals subject to managed care who remain in psychiatric unit beyond established discharge …

Rule 67:16:03:15 Application of other chapters. 67:16:03:15. 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, and 67:16:35. Source: 17 SDR 180…

Rule 67:16:04:01 Transferred. 67:16:04:01. Transferred to § 67:16:04:33.

Rule 67:16:04:02 Repealed. 67:16:04:02. Care facility agreement. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; repealed, 7 SDR 66, 7 SDR 89, effective July 1, 1981.

Rule 67:16:04:03 Transferred. 67:16:04:03. Transferred to § 67:45:01:02.

Rule 67:16:04:04 Repealed. 67:16:04:04. On-site medical review and inspection -- Skilled nursing facility. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; 2 SDR 71, effective April 29, 1976; 5 SDR 109, effective July 1, 1979; 7 SDR 23, effective Septe…

Rule 67:16:04:04.01 Repealed. 67:16:04:04.01. On-site medical evaluation and inspection -- Intermediate nursing facility. Repealed. Source: 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7 SDR 89, effective July 1, 1981; repealed, 18 SDR 67, effective October 13, 1991.

Rule 67:16:04:05 Transferred. 67:16:04:05. Transferred to § 67:45:02:03. Rule 67:16:04:05.01 Transferred. 67:16:04:05.01. Transferred to § 67:16:04:40.

Rule 67:16:04:05.01 Transferred. 67:16:04:05.01. Transferred to § 67:16:04:40.

Rule 67:16:04:06 Transferred. 67:16:04:06. Transferred to § 67:16:04:41. Rule 67:16:04:06.01 Transferred. 67:16:04:06.01. Transferred to § 67:16:04:42. Rule 67:16:04:06.02 Transferred. 67:16:04:06.02. Transferred to § 67:16:04:47. Rule 67:16:04:06.03 Transferred. 67:16:04:06.03. …

Rule 67:16:04:06.01 Transferred. 67:16:04:06.01. Transferred to § 67:16:04:42.

Rule 67:16:04:06.02 Transferred. 67:16:04:06.02. Transferred to § 67:16:04:47.

Rule 67:16:04:06.03 Transferred. 67:16:04:06.03. Transferred to § 67:16:04:43.

Rule 67:16:04:06.04 Transferred. 67:16:04:06.04. Transferred to § 67:16:04:49.

Rule 67:16:04:06.05 Transferred. 67:16:04:06.05. Transferred to § 67:16:04:53.

Rule 67:16:04:07 Transferred. 67:16:04:07. Transferred to § 67:16:04:34. Rule 67:16:04:07.01 Transferred. 67:16:04:07.01. Transferred to § 67:16:04:36. Rule 67:16:04:07.02 Transferred. 67:16:04:07.02. Transferred to § 67:16:04:37. Rule 67:16:04:07.03 Transferred. 67:16:04:07.03. …

Rule 67:16:04:07.01 Transferred. 67:16:04:07.01. Transferred to § 67:16:04:36.

Rule 67:16:04:07.02 Transferred. 67:16:04:07.02. Transferred to § 67:16:04:37.

Rule 67:16:04:07.03 Transferred. 67:16:04:07.03. Transferred to § 67:16:04:35.

Rule 67:16:04:07.04 Transferred. 67:16:04:07.04. Transferred to § 67:16:04:48.

Rule 67:16:04:07.05 Transferred. 67:16:04:07.05. Transferred to §§ 67:16:04:54 to 67:16:04:57, inclusive.

Rule 67:16:04:07.06 Transferred. 67:16:04:07.06. Transferred to § 67:16:04:39.

Rule 67:16:04:07.07 Transferred. 67:16:04:07.07. Transferred to § 67:16:04:58.

Rule 67:16:04:07.08 Repealed. 67:16:04:07.08. Reimbursements -- Facility's usual and customary charge -- Per diem rate. Repealed. Source: 17 SDR 50, effective October 7, 1990; repealed, 21 SDR 8, effective July 25, 1994.

Rule 67:16:04:08 Transferred. 67:16:04:08. Transferred to § 67:16:04:60. Rule 67:16:04:08.01 Transferred. 67:16:04:08.01. Transferred to § 67:45:02:02. Rule 67:16:04:08.02 Repealed. 67:16:04:08.02. Add-on payment -- Nutritional therapy. Repealed. Source: 15 SDR 68, effective Nove…

Rule 67:16:04:08.01 Transferred. 67:16:04:08.01. Transferred to § 67:45:02:02.