South Dakota Administrative Code

Rule 67:16:06:09 Repealed. 67:16:06:09. Claim requirements. Repealed. Source: 17 SDR 4, effective July 16, 1990; 17 SDR 200, effective July 1, 1991; 18 SDR 198, effective June 3, 1992; repealed, 23 SDR 197, effective May 26, 1997.

Rule 67:16:06:10 Application of other chapters. 67:16:06:10. 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 and 67:16:26. Source: 17 SDR 184, effective June 6, 1991; 23 SD…

Rule 67:16:07:01 Definitions. 67:16:07:01. Definitions. Terms used in this chapter mean: (1) "Flatfoot," a condition in which one or more arches in the foot have flattened out; (2) "Podiatrist," an individual who meets the licensure and certification requirements of SDCL 36-8-6 a…

Rule 67:16:07:02 Repealed. 67:16:07:02. Provider agreement. Repealed. Source: 1 SDR 30, effective October 13, 1974; repealed, 3 SDR 26, effective October 6, 1976; cross-reference added, 16 SDR 227, effective June 25, 1990. Cross-Reference: Participating provider, § 67:16:33:02.

Rule 67:16:07:03 Covered services -- Limits. 67:16:07:03. Covered services -- Limits. Podiatry services covered are limited to those surgical and nonsurgical podiatry procedures listed on the department's fee schedule website, unless excluded by § 67:16:07:04. Any podiatry servic…

67:16:07:04. Services not covered. The following podiatry services are not covered under the medical assistance program: (1) Stock orthopedic shoes, unless covered under chapter 67:16:11 for children less than twenty-one years of age, or built into a leg brace; (2) The treatment …

67:16:07:05. Rate of payment. A claim submitted under this chapter must be submitted at the podiatrist's usual and customary charge. Except for bilateral or multiple surgeries, payment is limited to the lesser of the provider's usual and customary charge or the fee listed on the …

Rule 67:16:07:05.01 Repealed. 67:16:07:05.01. Cost sharing. Repealed. Source: 16 SDR 114, effective January 15, 1990; 31 SDR 191, effective June 8, 2005; 42 SDR 51, effective October 13, 2015.

Rule 67:16:07:06 Utilization review. 67:16:07:06. Utilization review. Utilization review for podiatry services may be conducted on three levels: (1) Computerized claims processing; (2) Postpayment review; and (3) Peer review. Source: 1 SDR 30, effective October 13, 1974; repealed…

Rule 67:16:07:07 Billing requirements. 67:16:07:07. Billing requirements. A claim submitted under this chapter must be submitted at the provider's usual and customary charge and must contain the applicable procedure codes for the podiatry services provided. Source: 16 SDR 227, ef…

Rule 67:16:07:08 Claim requirements. 67:16:07:08. 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 67:16:07:09 Application of other chapters. 67:16:07:09. 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 184…

Rule 67:16:08:01 Definitions. 67:16:08:01. Definitions. Terms used in this chapter mean: (1) "Amblyopia," the condition that exists when there is reduced vision in an eye because it did not receive adequately focused retinal stimulus during early childhood; (2) "Anisometropia," t…

Rule 67:16:08:02 Repealed. 67:16:08:02. Provider 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; cross-reference added, 16 SDR 235, effective July 5, 1990. Cross-Reference: Participating…

Rule 67:16:08:03 Repealed. 67:16:08:03. Prior authorization of optometric services. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; repealed, 2 SDR 16, effective September 4, 1975.

Rule 67:16:08:04 Covered services -- Limits. 67:16:08:04. Covered services -- Limits. Optometric and optical services are subject to the limits established in this chapter. Covered services are limited to the services and supplies listed on the department's fee schedule website. …

Rule 67:16:08:05 Services not covered. 67:16:08:05. Services not covered. The department does not cover the following items or services and, if provided, reimbursement must be obtained from the recipient: (1) Extended wear or daily disposable contact lenses; (2) Regular eyeglasse…

Rule 67:16:08:06 Rate of payment. 67:16:08:06. Rate of payment. A claim submitted under this chapter must be submitted at the provider's usual and customary charge. Payment is limited to the lesser of the provider's usual and customary charge or the amount specified on the depart…

Rule 67:16:08:06.01 Billing requirements. 67:16:08:06.01. Billing requirements. Claims must be submitted at the provider's usual and customary charge and must contain the applicable procedure codes for the covered services provided. Source: 16 SDR 64, effective October 8, 1989; 1…

Rule 67:16:08:07 Utilization review. 67:16:08:07. Utilization review. Utilization review for optometric and optical services may be conducted on the following levels: (1) Computerized claims processing; (2) Postpayment review; and (3) Peer review. Source: 1 SDR 30, effective Octo…

Rule 67:16:08:08 Repealed. 67:16:08:08. Cost sharing. Repealed. Source: 9 SDR 164, effective June 30, 1983; 31 SDR 191, effective June 8, 2005; 35 SDR 49, effective September 10, 2008; 42 SDR 51, effective October 13, 2015.

Rule 67:16:08:09 Claim requirements. 67:16:08:09. 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 67:16:08:10 Application of other chapters. 67:16:08:10. 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 184…

Rule 67:16:08:11 Repealed. 67:16:08:11. Rate of payment -- Other optometric eye care. Repealed. Source: 20 SDR 135, effective February 22, 1994; 26 SDR 157, effective June 7, 2000; repealed, 35 SDR 49, effective September 10, 2008.

Rule 67:16:09:01 Definitions. 67:16:09:01. Definitions. Terms used in this chapter mean: (1) "Chiropractic services," those diagnostic and treatment services provided by a chiropractor to detect and treat one or more subluxations of the spine; (2) "Chiropractor," a person license…

Rule 67:16:09:02 Repealed. 67:16:09:02. Payments -- Provider agreement. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 77, effective May 29, 1975; repealed, 3 SDR 26, effective October 6, 1976; readopted, 5 SDR 109, effective July 1, 1979; repealed, 7 SDR 66, 7 SDR 89, effective Ju…

Rule 67:16:09:03 Covered services. 67:16:09:03. Covered services. Covered chiropractic services are limited to the procedures listed on the department's fee schedule website. Source: SL 1975, ch 16, § 1; 1 SDR 77, effective May 29, 1975; 2 SDR 88, effective July 1, 1976; repealed…

Rule 67:16:09:03.01 X ray to substantiate service -- Limits. 67:16:09:03.01. X ray to substantiate service -- Limits. Repealed. Source: 16 SDR 227, effective June 24, 1990; 33 SDR 137, effective March 7, 2007; repealed, 34 SDR 68, effective September 12, 2007.

Rule 67:16:09:04 Repealed. 67:16:09:04. Nonreimbursable services. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 77, effective May 29, 1975; repealed, 3 SDR 26, effective October 6, 1976; readopted, 5 SDR 109, effective July 1, 1979; 7 SDR 66, 7 SDR 89, effective July 1, 1981; repe…

Rule 67:16:09:05 Billing requirements. 67:16:09:05. Billing requirements. A claim submitted under this chapter must be submitted at the provider's usual and customary charge and must contain the applicable procedure codes for the chiropractic services provided. A provider may not…

Rule 67:16:09:05.01 Rate of payment. 67:16:09:05.01. Rate of payment. Payment for chiropractic services is limited to the lesser of the provider's usual and customary charge or the fee contained on the department's fee schedule website. Manual manipulation of the spine is limited…

Rule 67:16:09:06 Utilization review. 67:16:09:06. Utilization review. Utilization review of services covered under this chapter may be conducted on any of the following three levels: (1) Computerized claims processing; (2) Postpayment review; and (3) Peer reviews. Source: SL 1975…

Rule 67:16:09:07 Repealed. 67:16:09:07. Cost sharing. Repealed. Source: SL 1975, ch 16, § 1; repealed, 3 SDR 26, effective October 6, 1976; readopted, 9 SDR 164, effective June 30, 1983; 18 SDR 135, effective February 25, 1992; 20 SDR 135, effective February 22, 1994; 31 SDR 191,…

Rule 67:16:09:08 Claim requirements. 67:16:09:08. 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 67:16:09:09 Application of other chapters. 67:16:09:09. 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 184…

Rule 67:16:10:01 Repealed. 67:16:10:01. Definitions. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; 4 SDR 35, effective December 22, 1977; 7 SDR 66, 7 SDR 89, effective July 1, 1981; repealed, 24 SDR 144, effective April 30, 1998.

Rule 67:16:10:02 Repealed. 67:16:10:02. Provider 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; cross-reference added, 16 SDR 227, effective June 25, 1990. Cross-Reference: Participatin…

Rule 67:16:10:03 Repealed. 67:16:10:03. Scope of services. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; 7 SDR 66, 7 SDR 89, effective July 1, 1981; repealed, 11 SDR 26, effective August 21, 1984.

Rule 67:16:10:04 Repealed. 67:16:10:04. Prior authorization of services required. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; 1 SDR 66, effective April 6, 1975; 1 SDR 73, effective July 1, 1975; 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7 …

Rule 67:16:10:05 Repealed. 67:16:10:05. Written notice of rehabilitation hospital services. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; repealed, 2 SDR 88, effective June 30, 1976.

Rule 67:16:10:06 Repealed. 67:16:10:06. Basis of payment. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 17 SDR 200, effective July 1, 1991; repealed, 24 SDR 144, effective April 30, 1998.

Rule 67:16:10:07 Repealed. 67:16:10:07. Required financial reports. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; 7 SDR 66, 7 SDR 89, effective July 1, 1981; repealed, 24 SDR 144, effective April 30, 1998.

Rule 67:16:10:08 Repealed. 67:16:10:08. Utilization review. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; 7 SDR 66, 7 SDR 89, effective July 1, 1981; repealed, 24 SDR 144, effective April 30, 1998.

Rule 67:16:10:09 Repealed. 67:16:10:09. Cost sharing. Repealed. Source: SL 1975, ch 16, § 1; 9 SDR 164, effective June 30, 1983; 13 SDR 8, effective August 3, 1986; repealed, 24 SDR 144, effective April 30, 1998.

Rule 67:16:10:10 Repealed. 67:16:10:10. Claim requirements. Repealed. Source: 17 SDR 4, effective July 16, 1990; 18 SDR 78, effective November 4, 1991; 19 SDR 26, effective August 23, 1992; 19 SDR 128, effective March 11, 1993; 20 SDR 149, effective March 21, 1994; 21 SDR 183, ef…

Rule 67:16:10:11 Repealed. 67:16:10:11. Application of other chapters. Repealed. Source: 17 SDR 184, effective June 6, 1991; repealed, 24 SDR 144, effective April 30, 1998.

Rule 67:16:11:01 Definitions. 67:16:11:01. Definitions. Terms used in this chapter mean: (1) "Early and periodic screening, diagnosis, and treatment" or "EPSDT," screening and diagnostic services available to eligible individuals under 21 years of age to determine physical or men…

Rule 67:16:11:01.01 Repealed. 67:16:11:01.01. Contractor to provide certain services. Repealed. Source: 23 SDR 197, effective May 26, 1997; repealed, 35 SDR 88, effective October 23, 2008.

Rule 67:16:11:02 Eligibility requirements. 67:16:11:02. Eligibility requirements. Except for qualified Medicare beneficiaries eligible under chapter 67:16:30, an individual is eligible for assistance under the EPSDT program if the individual is under 21 years of age and otherwise…

Rule 67:16:11:03 Covered services -- Limits. 67:16:11:03. Covered services -- Limits. EPSDT services are limited to the following: (1) Screening services conducted under the provisions of §§ 67:16:11:04 and 67:16:11:04.01; (2) Orthodontic services when the requirements of § 67:16…