South Dakota Administrative Code

Rule 67:16:14:06.10 Coverage limits -- Growth hormones. 67:16:14:06.10. Coverage limits -- Growth hormones. Growth hormones are covered when the use of the drug has received prior authorization from the department. Either the prescribing physician, other licensed practitioner, or…

Rule 67:16:14:06.11 Required use of tamper-resistant prescriptions. 67:16:14:06.11. Required use of tamper-resistant prescriptions. For written prescriptions, the cost of the prescribed drug or over-the-counter item is not covered unless the prescription was written on a tamper-r…

Rule 67:16:14:07 Repealed. 67:16:14:07. Time factor relating to payment. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 77, effective May 29, 1975; repealed, 7 SDR 66, 7 SDR 89, effective July 1, 1981.

Rule 67:16:14:08 Utilization review. 67:16:14:08. Utilization review. Utilization review for prescription drug services may be conducted on three levels: (1) Computerized claims processing; (2) Postpayment review; and (3) Peer review. Source: SL 1975, ch 16, § 1; 1 SDR 77, effect…

Rule 67:16:14:09 Repealed. 67:16:14:09. Maximum allowable payment. Repealed. Source: 1 SDR 77, effective May 29, 1975; repealed, 7 SDR 23, effective September 18, 1980.

Rule 67:16:14:10 Repealed. 67:16:14:10. Cost sharing. Repealed. Source: 2 SDR 46, effective December 30, 1975; 3 SDR 20, effective September 19, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 9 SDR 164, effective June 30, 1983; 21 SDR 68, effective October 13, 1994; 31 SDR 191…

Rule 67:16:14:11 Repealed. 67:16:14:11. Waiver of multiple-source drug payment limit. Repealed. Source: 9 SDR 164, effective June 30, 1983; 10 SDR 68, effective January 1, 1984; 13 SDR 8, effective August 3, 1986; 14 SDR 46, effective September 28, 1987; 14 SDR 153, effective May…

Rule 67:16:14:12 Repealed. 67:16:14:12. Drug reimbursement if requirements not met. Repealed. Source: 9 SDR 164, effective June 30, 1983; 15 SDR 74, effective November 20, 1988; 16 SDR 234, effective July 1, 1990; 22 SDR 93, effective January 7, 1996; 29 SDR 113, effective Februa…

Rule 67:16:14:13 Billing requirements. 67:16:14:13. Billing requirements. Except for items dispensed under the provisions of subdivision 67:16:14:06.06(2) or § 67:16:14:06.09, claims for items provided under this chapter must be submitted at the provider's usual and customary cha…

Rule 67:16:14:14 Claim requirements. 67:16:14:14. Claim requirements. A claim for items provided under this chapter must be submitted on a claim form or in an electronic format that contains the following information: (1) The recipient's full name; (2) The recipient's medical ass…

Rule 67:16:14:15 Application of other chapters. 67:16:14:15. 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, 67:16:35, and 67:16:39, if appli…

Rule 67:16:14:16 Over-the-counter items covered. 67:16:14:16. Over-the-counter items covered. Over-the-counter items covered under this chapter are limited to drugs which meet the following requirements: (1) The department has approved coverage of the drug based on the P and T co…

Rule 67:16:14:17 Drug review by P and T committee. 67:16:14:17. Drug review by P and T committee. When reviewing OTC drugs for coverage by the department, the P and T committee shall consider the drug's clinical efficacy, safety, and cost-effectiveness. Following the committee's …

Rule 67:16:14:18 Prior authorization for certain prescription drugs. 67:16:14:18. Prior authorization for certain prescription drugs. The department requires prior approval of certain prescription drugs. Based on recommendations made by the department's P and T committee, the dep…

Rule 67:16:14:19 P and T committee to make recommendations to department. 67:16:14:19. P and T committee to make recommendations to department. The P and T committee's recommendations to the department for those drugs requiring prior authorization from the department must include…

Rule 67:16:14:20 Notice to interested parties before drug placed on list -- Opportunity for interested parties to present data, opinions, and arguments. 67:16:14:20 Notice to interested parties before drug placed on list -- Opportunity for interested parties to present data, opin…

Rule 67:16:14:21 Notice to providers when drug is to be placed on list. 67:16:14:21 Notice to providers when drug is to be placed on list. At least 30 days before the department implements the prior authorization requirements for a particular drug, the department shall provide a …

Rule 67:16:14:22 Cost of drug not covered if substitution not made or prior authorization obtained. 67:16:14:22 Cost of drug not covered if substitution not made or prior authorization obtained. If the department informs a pharmacist that a requested drug requires prior authoriza…

Rule 67:16:14:23 Emergency supplies. 67:16:14:23 Emergency supplies. If an emergency situation exists and a prior authorization requirement cannot be submitted and a response received within 24 hours, the pharmacy may dispense and receive reimbursement from the department for a f…

Rule 67:16:14:24 Appeal process. 67:16:14:24 Appeal process. If the department denies the prior authorization request, the medical professional may appeal the decision. At the time of the denial, the department shall advise the medical professional of the procedures to follow to …

Rule 67:16:16:01 Definitions. 67:16:16:01. Definitions. Terms used in this chapter mean: (1) "Facility," a public or private institution licensed by an agency of the state of South Dakota or owned and operated by the state of South Dakota and certified by the department as a prov…

Rule 67:16:16:02 Repealed. 67:16:16:02. Care facility agreement required. Repealed. Source: 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 provid…

Rule 67:16:16:03 Determination of need for care. 67:16:16:03. Determination of need for care. An eligible recipient's need for services provided by a facility shall be determined by the review team using their professional judgment of information from other professional sources b…

Rule 67:16:16:04 On-site review and inspection. 67:16:16:04. On-site review and inspection. The review team shall conduct an on-site review and inspection of each facility at least annually. Source: 1 SDR 30, effective October 13, 1974; 7 SDR 66, 7 SDR 89, effective July 1, 1981.…

Rule 67:16:16:05 Required financial reports. 67:16:16:05. Required financial reports. Facilities shall submit financial and statistical data to the department for the state's or facility's fiscal accounting period on forms supplied by the department. At the department's request, …

Rule 67:16:16:06 Rate of payment. 67:16:16:06. Rate of payment. Payment to a participating provider for services provided by a facility shall be determined by the department based on reasonable costs. Source: 1 SDR 30, effective October 13, 1974; 7 SDR 66, 7 SDR 89, effective Jul…

Rule 67:16:16:07 Other resources of a resident. 67:16:16:07. Other resources of a resident. All income received by or in behalf of a resident shall be applied first against the recognized personal maintenance allowance for the individual and the balance shall be credited to the m…

Rule 67:16:16:08 Extent of payment. 67:16:16:08. Extent of payment. Payment to facilities shall be made in behalf of a recipient for resident days only. Resident days include the day of admission but exclude the day of discharge. Source: 1 SDR 30, effective October 13, 1974; 7 SD…

Rule 67:16:16:09 Payments for reserved bed days. 67:16:16:09. Payments for reserved bed days. Payment shall be made in behalf of an eligible individual when it is necessary to reserve a recipient's bed during temporary absence from a skilled nursing or intermediate care facility …

Rule 67:16:16:10 Utilization review. 67:16:16:10. Utilization review. Services provided by facilities are subject to utilization review on three levels: (1) At the time of admission; (2) Computerized claims processing; and (3) Annual classification review. Source: 1 SDR 30, effec…

Rule 67:16:16:11 Application of other chapters. 67:16:16:11. 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 67:16:24:01 Definitions. 67:16:24:01. Definitions. Terms used in this chapter mean: (1) "Activities of daily living," tasks performed routinely by a person to maintain physical functioning and personal care, including transferring, moving about, dressing, grooming, toileting…

Rule 67:16:24:02 Repealed. 67:16:24:02. Payments -- Provider agreement. Repealed. Source: 5 SDR 109, effective July 1, 1979; repealed, 7 SDR 66, 7 SDR 89, effective July 1, 1981; cross-reference added, 16 SDR 235, effective July 5, 1990. Cross-Reference: Participating provider, §…

Rule 67:16:24:02.01 Eligibility. 67:16:24:02.01. Eligibility. To be eligible for services under this chapter, the individual must be eligible for Medicaid under the provisions of article 67:46 and the assessment prepared under the provisions of § 67:16:24:03.02 must indicate a ne…

67:16:24:03. Services covered. Personal care services are medically necessary services contained in the recipient's case service plan and provided in the recipient's residence. Only the following personal care services are covered: (1) Basic personal care and grooming, including …

Rule 67:16:24:03.01 Limitation on hours of services. 67:16:24:03.01. Limitation on hours of services. An individual qualifying for services under this chapter is limited to no more than 500 hours of services annually. The covered items and services provided under this chapter for…

67:16:24:03.02. Needs assessment. After an individual has been determined eligible for services under this chapter, the department must assess the individual's personal care service needs. The department shall complete the needs assessment at least once every twelve months. The n…

Rule 67:16:24:03.03 Case service plan. 67:16:24:03.03. Case service plan. The department shall develop a case service plan for each individual eligible for personal care services. The plan shall be based on the individual's needs assessment and shall contain items such as the fol…

67:16:24:04. Rate of payment. Payment for personal care 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. Source: 5 SDR 109, effective July 1, 1979; 7 SDR 66, 7 SDR 89, effective July 1, 1…

Rule 67:16:24:05 Utilization review. 67:16:24:05. Utilization review. The department may provide utilization review of personal care services through computerized claims processing and postpayment review. Source: 5 SDR 109, effective July 1, 1979; 7 SDR 66, 7 SDR 89, effective Ju…

Rule 67:16:24:06 Claim requirements. 67:16:24:06. Claim requirements. A claim for services provided under this chapter must be submitted on a form available from the department or the claim may be electronically transmitted through a system approved by the department. The claim m…

67:16:24:07. Discontinuance or denial of services. The department may discontinue or deny services provided under this chapter when the department exhausts its resources for providing the services, the individual can no longer benefit from the services provided, or the individual…

Rule 67:16:25:01 Definitions. 67:16:25:01. Definitions. Terms used in this chapter mean: (1) "Air ambulance," an aircraft, fixed-wing or helicopter, that is designed or can be quickly modified to provide emergency transportation of wounded, injured, sick, invalid, or incapacitate…

Rule 67:16:25:02 Ambulance services covered. 67:16:25:02. Ambulance services covered. Ambulance services are limited to medically necessary ground ambulance services at the pick-up point and ground or air ambulances services transporting the recipient locally or to the nearest me…

Rule 67:16:25:02.01 Air ambulance restrictions. 67:16:25:02.01. Air ambulance restrictions. Air ambulance services must meet all of the following criteria: (1) The transportation must be medically necessary because of time, distance, emergency, or other factors or when transporta…

67:16:25:03. Rate of payment -- Ground and air ambulance services. The rate of payment for ground or air ambulance service is the base fee, loaded mileage, and other medically necessary covered services. Payment is limited to the lesser of the provider's usual and customary charg…

Rule 67:16:25:03.01 Repealed. 67:16:25:03.01. Rate of payment -- Ground ambulance -- Advanced life support. Repealed. Source: 13 SDR 8, effective August 3, 1986; 16 SDR 234, effective July 1, 1990; 17 SDR 201, effective July 1, 1991; 21 SDR 68, effective October 13, 1994; 22 SDR …

Rule 67:16:25:03.02 Repealed. 67:16:25:03.02. Rate of payment -- Medical air transport. Repealed. Source: 16 SDR 234, effective July 1, 1990; 17 SDR 201, effective July 1, 1991; 21 SDR 68, effective October 13, 1994; 22 SDR 94, effective January 10, 1996; 26 SDR 157, effective Ju…

Rule 67:16:25:03.03 Repealed. 67:16:25:03.03 Rate of payment -- Basic life support air ambulance. Repealed. Source: 17 SDR 201, effective July 1, 1991; 21 SDR 68, effective October 13, 1994; 22 SDR 94, effective January 10, 1996; 26 SDR 157, effective June 7, 2000; repealed, 35 S…

Rule 67:16:25:03.04 Repealed. 67:16:25:03.04. Rate of payment -- Advanced life support air ambulance. Repealed. Source: 17 SDR 201, effective July 1, 1991; 21 SDR 68, effective October 13, 1994; 22 SDR 94, effective January 10, 1996; 26 SDR 157, effective June 7, 2000; 28 SDR 166…