South Dakota Administrative Code

Rule 67:16:11:11 Utilization review. 67:16:11:11. Utilization review. Utilization review for EPSDT services may be conducted on three levels: (1) Computerized claims processing; (2) Postpayment review; and (3) Peer review. Source: SL 1975, ch 16, § 1; 2 SDR 74, effective May 13, …

Rule 67:16:11:12 Repealed. 67:16:11:12. Cost sharing. Repealed. Source: 9 SDR 164, effective June 30, 1983; 15 SDR 167, effective May 11, 1989; 17 SDR 37, effective September 11, 1990; 19 SDR 82, effective December 7, 1992; 31 SDR 191, effective June 8, 2005; repealed, 35 SDR 88,…

Rule 67:16:11:13 Billing requirements. 67:16:11:13. Billing requirements. A provider submitting a claim for reimbursement under this chapter must submit the claim at the provider's usual and customary charge. The laboratory which actually performs the laboratory test must submit …

Rule 67:16:11:13.01 Repealed. 67:16:11:13.01. Billing requirements -- Home-based therapy services. Repealed. Source: 18 SDR 98, effective December 9, 1991; repealed, 35 SDR 88, effective October 23, 2008.

Rule 67:16:11:13.02 Repealed. 67:16:11:13.02. Billing requirements -- Orthodontic treatment. Repealed. Source: 19 SDR 56, effective October 19, 1992; 19 SDR 202, effective July 5, 1993; repealed, 23 SDR 197, effective May 26, 1997.

Rule 67:16:11:14 Claim requirements. 67:16:11:14. Claim requirements. A claim for services covered under this chapter must be submitted according to the following requirements: (1) For orthodontic services, follow the claim requirements of § 67:16:11:17; (2) For private duty nurs…

Rule 67:16:11:15 Transferred. 67:16:11:15. Transferred to § 67:54:08:11.

Rule 67:16:11:16 Transferred. 67:16:11:16. Transferred to § 67:16:42:13.

Rule 67:16:11:17 Claim requirements -- Orthodontia services. 67:16:11:17. Claim requirements -- Orthodontia services. A claim for orthodontia services provided in this chapter must be submitted on a form or in an electronic format that contains the following information: (1) The …

Rule 67:16:11:18 Repealed. 67:16:11:18. Claim requirements -- Dental services. Repealed. Source: 17 SDR 37, effective September 11, 1990; 17 SDR 200, effective July 1, 1991; 18 SDR 209, effective June 23, 1992; repealed, 23 SDR 197, effective May 26, 1997.

Rule 67:16:11:19 Repealed. 67:16:11:19. Claim requirements -- Psychological services. Repealed. Source: 17 SDR 37, effective September 11 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…

Rule 67:16:11:19.01 Repealed. 67:16:11:19.01. Claim requirements -- Home-based therapy services. Repealed. Source: 18 SDR 98, effective December 9, 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, …

Rule 67:16:11:19.02 Claim requirements -- Private duty nursing -- Extended home health aide services. 67:16:11:19.02. Claim requirements -- Private duty nursing -- Extended home health aide services. A claim for private duty nursing and extended home health aide services provided…

Rule 67:16:11:19.03 Claim requirements -- Screenings. 67:16:11:19.03. Claim requirements -- Screenings. A claim for screening 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 f…

Rule 67:16:11:19.04 Claim requirements -- Immunizations. 67:16:11:19.04. Claim requirements -- Immunizations. A claim for immunization services provided under this chapter must be submitted on a form or in an electronic format that contains the following information: (1) The reci…

Rule 67:16:11:20 Application of other chapters. 67:16:11:20. 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 67:16:12:01 Definitions. 67:16:12:01. Definitions. Terms used in this chapter mean: (1) "Family planning services," medically approved services and supplies which are available for individuals of childbearing age for the purpose of providing freedom of choice to determine, i…

Rule 67:16:12:02 Scope of services. 67:16:12:02. Scope of services. The department may provide the following family planning services to eligible individuals: (1) Diagnosis; (2) Treatment; (3) Drugs, supplies, devices, and procedures, except agents to promote fertility; and (4) R…

Rule 67:16:12:02.01 Services not covered. 67:16:12:02.01. Services not covered. The following services are not covered: (1) Agents to promote fertility; (2) Procedures to reverse a previous sterilization; (3) Removal of implanted contraceptive capsules if done to reverse the inte…

Rule 67:16:12:03 Rate of payment. 67:16:12:03. Rate of payment. The department shall make payments according to the applicable provisions of chapters 67:16:01, 67:16:02, 67:16:03, 67:16:05, 67:16:13, 67:16:14, 67:16:28, and 67:16:44 for services provided under this chapter. Sourc…

Rule 67:16:12:04 Utilization review. 67:16:12:04. Utilization review. The department may conduct utilization reviews for family planning services on the following levels: (1) Computerized claims processing; (2) Postpayment review; and (3) Peer reviews. Source: SL 1975, ch 16, § 1…

Rule 67:16:12:05 Billing requirements. 67:16:12:05. Billing requirements. A claim submitted under this chapter must be submitted at the provider's usual and customary charge and in accordance with the applicable provisions of chapters 67:16:01, 67:16:02, 67:16:03, 67:16:05, 67:16…

Rule 67:16:12:06 Claim requirements. 67:16:12:06. Claim requirements. A claim for services covered under § 67:16:12:02 must be submitted according to the following: (1) If the claim relates to a physician's service, follow the claim requirements of chapter 67:16:02; (2) If the cl…

Rule 67:16:12:07 Application of other chapters. 67:16:12:07. 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 67:16:13:01 Definitions. 67:16:13:01. Definitions. The term, community mental health center, means any facility accredited pursuant to article 67:62. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; 4 SDR 88, effective June 26, 1978; 7 SDR 66, 7 SDR 89, eff…

Rule 67:16:13:02 Repealed. 67:16:13:02. Provider agreement. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; 4 SDR 88, effective June 26, 1978; repealed, 7 SDR 66, 7 SDR 89, effective July 1, 1981; cross-reference added, 16 SDR 234, effective July 2, 1…

Rule 67:16:13:03 Rate of payment. 67:16:13:03. Rate of payment. Payment to a community mental health center is limited to the provider's usual and customary charge or the fee contained on the department's fee schedule website, whichever is less. Source: 1 SDR 30, effective Octobe…

Rule 67:16:13:04 Covered services. 67:16:13:04. Covered services. To be covered, services must be provided by an agency who meets the requirements of chapter 67:62:02. Covered services are limited to the services described in chapters 67:62:10, 67:62:11, 67:62:12, and 67:62:13. S…

Rule 67:16:13:05 Repealed. 67:16:13:05. Covered clinic services. Repealed. Source: 4 SDR 88, effective June 26, 1978; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 16 SDR 234, effective July 2, 1990; 22 SDR 6, effective July 26, 1995; 43 SDR 80, effective December 5, 2016.

Rule 67:16:13:06 Utilization review. 67:16:13:06. Utilization review. Utilization review for mental health center and clinic services may be conducted on the following levels: (1) Computerized claims processing; (2) Postpayment review; and (3) Peer reviews. Source: 4 SDR 88, effe…

Rule 67:16:13:07 Repealed. 67:16:13:07. Cost sharing. Repealed. Source: 9 SDR 164, effective June 30, 1983; 37 SDR 53, effective September 23, 2010; 42 SDR 51, effective October 13, 2015.

Rule 67:16:13:08 Billing requirements. 67:16:13:08. Billing requirements. A claim submitted under this chapter must be submitted at the provider's usual and customary charge. Source: 16 SDR 234, effective July 2, 1990; 19 SDR 165, effective May 3, 1993; 22 SDR 6, effective July 2…

Rule 67:16:13:09 Claim requirements. 67:16:13:09. Claim requirements. 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…

Rule 67:16:13:10 Application of other chapters. 67:16:13:10. 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 67:16:14:01 Definitions. 67:16:14:01. Definitions. Terms defined in SDCL 36-11-2 have the same meaning when used in this chapter. In addition, terms used in this chapter mean: (1) "Bioavailability," the degree to which a drug or other substance becomes available to the targe…

Rule 67:16:14:02 Repealed. 67:16:14:02. Pharmacist agreement. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 77, effective May 29, 1975; repealed, 7 SDR 66, 7 SDR 89, effective July 1, 1981; cross-reference added, 16 SDR 234, effective July 1, 1990. Cross-Reference: Participating p…

Rule 67:16:14:02.01 PHS provider identification number. 67:16:14:02.01. PHS provider identification number. A PHS provider must have a PHS provider agreement with the department. In addition to the provider identification number assigned under the provisions of § 67:16:33:02, the…

Rule 67:16:14:03 Repealed. 67:16:14:03. Drugs dispensed by prescriber. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 77, effective May 29, 1975; 7 SDR 66, 7 SDR 89, effective July 1, 1981; repealed, 14 SDR 153, effective May 23, 1988; cross-reference added, 16 SDR 234, effective J…

Rule 67:16:14:04 Items and services covered. 67:16:14:04. Items and services covered. A prescription is required for all of the items and services and nonlegend drugs and supplies covered under this section. The following prescription drugs, biologicals, and related items and ser…

67:16:14:05. Items and services not covered. In addition to the items and services not specifically listed in § 67:16:14:04, the following items and services are not covered under this chapter: (1) Nonlegend prescription drugs and over-the-counter items and medical supplies excep…

Rule 67:16:14:06 Payment for items dispensed by pharmacy. 67:16:14:06. Payment for items dispensed by pharmacy. Payment for items covered under this chapter and dispensed by a pharmacy is made at the lowest of the following: (1) The provider's usual and customary charge; (2) The …

Rule 67:16:14:06.01 Repealed. 67:16:14:06.01. Payment for multiple-source drugs -- Federal list. Repealed. Source: 14 SDR 153, effective May 23, 1988; 15 SDR 74, effective November 20, 1988; 16 SDR 33, effective August 20, 1989; 16 SDR 214, effective June 11, 1990; 17 SDR 86, eff…

Rule 67:16:14:06.02 State MAC list. 67:16:14:06.02. State MAC list. Drugs covered under the state MAC list are limited to those drugs that are widely and consistently available to South Dakota pharmacies at a price that is less than the consolidated price. The department, in cons…

Rule 67:16:14:06.03 Dispensing fee for maintenance drugs. 67:16:14:06.03. Dispensing fee for maintenance drugs. Dispensing fee payments for maintenance drugs or items are limited to one each month for each drug or item except for the following: (1) Schedule II, III, and IV contro…

Rule 67:16:14:06.04 Payment of container costs for drugs dispensed under unit dose system. 67:16:14:06.04. Payment of container costs for drugs dispensed under unit dose system. Payment for drugs dispensed under a unit dose system includes a container cost in addition to the amou…

Rule 67:16:14:06.05 Prescriptions for family planning items. 67:16:14:06.05. Prescriptions for family planning items. An initial prescription for a family planning item may be dispensed in less than a three-month supply until maintenance is established. Once maintenance is establ…

Rule 67:16:14:06.06 Payment for drugs dispensed by physician. 67:16:14:06.06. Payment for drugs dispensed by physician. Payment for items covered under this chapter and dispensed by a physician or other licensed practitioner is made according to one of the following: (1) If a pha…

Rule 67:16:14:06.07 Repealed. 67:16:14:06.07. Coverage limits -- Azidothymidine.Repealed. Source: 14 SDR 153, effective May 23, 1988; 16 SDR 234, effective July 1, 1990; repealed, 31 SDR 214, effective July 6, 2005.

Rule 67:16:14:06.08 Repealed. 67:16:14:06.08. Coverage limits -- Clozaril.Repealed. Source: 18 SDR 50, effective September 15, 1991; repealed, 31 SDR 214, effective July 6, 2005.

Rule 67:16:14:06.09 Payment for items dispensed by PHS provider. 67:16:14:06.09. Payment for items dispensed by PHS provider. Except for family planning supplies, payment for items dispensed by a PHS provider is limited to the cost of the item plus $4.30 or three percent, whichev…