South Dakota Administrative Code

Rule 67:16:26:08 Reimbursement from third-party collections. 67:16:26:08. Reimbursement from third-party collections. If the department has made payments in behalf of a recipient, providers and recipients must reimburse the department when a payment is received from a third-party…

Rule 67:16:26:09 Claims review. 67:16:26:09. Claims review. The department may conduct a claims review for third-party liability in the following manner: (1) By reviewing all claims for services that could have been the result of an accident; (2) By reviewing paid claims for assu…

Rule 67:16:26:10 Application of chapter. 67:16:26:10. Application of chapter. The rules in this chapter apply to all enrolled providers and recipients. Source: 17 SDR 184, effective June 6, 1991. General Authority: SDCL 28-6-1. Law Implemented: SDCL 28-6-1.

Rule 67:16:28:00 Definitions. 67:16:28:00. Definitions. Terms used in this chapter mean: (1) "Ambulatory surgical center" or "ASC," a facility which operates exclusively for the purposes of providing surgical services to patients not requiring hospitalization. Source: 16 SDR 234,…

Rule 67:16:28:01 Eligible ambulatory surgical centers. 67:16:28:01. Eligible ambulatory surgical centers. Reimbursement for ambulatory surgical center (ASC) services under this chapter is limited to a facility which is not a hospital and which is an approved ASC provider under Me…

Rule 67:16:28:02 Services included in ASC reimbursement. 67:16:28:02. Services included in ASC reimbursement. The ASC facility services that are reimbursable under this chapter include services such as the following: (1) Nursing, technician, and related services; (2) Use of ASC f…

Rule 67:16:28:03 Services not included in ASC reimbursement. 67:16:28:03. Services not included in ASC reimbursement. ASC facility services reimbursable under this chapter do not include items and services for which payment may be made under other provisions of this article, such…

Rule 67:16:28:04 Surgical services covered. 67:16:28:04. Surgical services covered. Surgical procedures covered under this chapter are limited to those procedures contained on the department's fee schedule website. The procedures and associated rates of payment are subject to rev…

Rule 67:16:28:05 Rate of payment. 67:16:28:05. Rate of payment. The rate of payment for the different groups of covered ambulatory surgical center services is contained on the department's fee schedule website. The rates of payment for the different groups are subject to review a…

Rule 67:16:28:06 Payment for multiple procedures. 67:16:28:06. Payment for multiple procedures. If one covered surgical procedure is performed in a single operative session, payment is 100 percent of the established reimbursement rate. If more than one surgical procedure is perfo…

Rule 67:16:28:07 Repealed. 67:16:28:07. Cost sharing. Repealed. Source: 11 SDR 86, effective December 30, 1984; 23 SDR 113, effective January 12, 1997; 42 SDR 51, effective October 13, 2015.

Rule 67:16:28:08 Utilization review. 67:16:28:08. Utilization review. Utilization review for ASC services shall be provided by the following: (1) Computerized claims processing; (2) Postpayment monitoring; and (3) Peer review. Source: 11 SDR 86, effective December 30, 1984; 16 SD…

Rule 67:16:28:09 Billing requirements. 67:16:28:09. 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. General Authority: SDCL 28-6-1. Law Implemented: SDCL 28-6-1.…

Rule 67:16:28:10 Claim requirements. 67:16:28:10. 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 67:16:28:11 Application of other chapters. 67:16:28:11. 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 67:16:29:01 Definitions. 67:16:29:01. Definitions. Terms used in this chapter mean: (1) "Augmentative communication device," equipment used to overcome or ameliorate an individual's inability to communicate due to a disease or medical condition; (2) "Maintenance," servicing …

Rule 67:16:29:02 Medical equipment covered. 67:16:29:02. Medical equipment covered. Covered medical equipment includes medical equipment, prosthetic devices, and medical supplies required to improve the functioning of a malformed body part or treatment of an illness or injury, wh…

Rule 67:16:29:02.01 Repealed. 67:16:29:02.01. Pressure reduction therapy -- Limits. Repealed. Source: 16 SDR 239, effective July 9, 1990; 42 SDR 51, effective October 13, 2015; 44 SDR 94, effective December 4, 2017.

Rule 67:16:29:02.02 Repealed. 67:16:29:02.02. Pressure reduction therapy -- Requirements for prior authorization. Repealed. Source: 16 SDR 239, effective July 9, 1990; 42 SDR 51, effective October 13, 2015.

Rule 67:16:29:02.03 Repealed. 67:16:29:02.03. Pressure reduction therapy -- Required documentation. Repealed. Source: 16 SDR 239, effective July 9, 1990; 44 SDR 94, effective December 4, 2017.

Rule 67:16:29:02.04 Repealed. 67:16:29:02.04. Hearing aids -- Limits. Repealed. Source: 17 SDR 194, effective July 1, 1991; 18 SDR 210, effective June 23, 1992; 35 SDR 49, effective September 10, 2008; 42 SDR 51, effective October 13, 2015; 44 SDR 94, effective December 4, 2017.

Rule 67:16:29:02.05 Repealed. 67:16:29:02.05. Lymphedema pumps -- Limits. Repealed. Source: 22 SDR 138, effective May 2, 1996; 44 SDR 94, effective December 4, 2017.

Rule 67:16:29:02.06 Repealed. 67:16:29:02.06. Lymphedema pumps -- Prior authorization -- Required documentation. Repealed. Source: 22 SDR 138, effective May 2, 1996; 44 SDR 94, effective December 4, 2017.

Rule 67:16:29:02.07 Repealed. 67:16:29:02.07. Augmentative communication device -- Modification -- Prior authorization -- Required documentation. Repealed. Source: 24 SDR 11, effective August 4, 1997; 44 SDR 94, effective December 4, 2017.

Rule 67:16:29:02.08 Repealed. 67:16:29:02.08. Requirements for supervising speech pathologist. Repealed. Source: 24 SDR 11, effective August 4, 1997; 44 SDR 94, effective December 4, 2017.

Rule 67:16:29:02.09 Repealed. 67:16:29:02.09. Augmentative communication device -- Assessment requirements. Repealed. Source: 24 SDR 11, effective August 4, 1997; 44 SDR 94, effective December 4, 2017.

Rule 67:16:29:02.10 Repealed. 67:16:29:02.10. Augmentative communication device -- Maintenance and repair. Repealed. Source: 24 SDR 11, effective August 4, 1997; 44 SDR 94, effective December 4, 2017.

Rule 67:16:29:02.11 Repealed. 67:16:29:02.11. Augmentative communication device -- Purchase of warranty. Repealed. Source: 24 SDR 11, effective August 4, 1997; 44 SDR 94, effective December 4, 2017.

Rule 67:16:29:03 Maintenance and repair of medical equipment. 67:16:29:03. Maintenance and repair of medical equipment. Payment for the maintenance and repair of medical equipment is covered when: (1) The item is covered by South Dakota Medicaid; (2) The recipient's condition mee…

67:16:29:04. Limits on the provision of medical equipment and supplies. The provision of medical equipment and supplies to a recipient is permitted when: (1) The equipment and supplies are medically necessary for the recipient according to § 67:16:01:06.02; (2) The equipment and …

Rule 67:16:29:04.01 Equipment not covered. 67:16:29:04.01. Equipment not covered. The following are not considered medical equipment or medical supplies and are not covered due to not meeting the definitions in § 67:16:29:01: (1) Self-help devices. A self-help device is equipment…

67:16:29:04.02. Provider to maintain records. The provider prescribing medical equipment must document the medical necessity in the recipient's medical record. Unless otherwise specified in the department's coverage criteria, the provider shall update the medical necessity docume…

Rule 67:16:29:05 Rental or purchase at department's discretion -- Ownership of purchased equipment. 67:16:29:05. Rental or purchase at department's discretion -- Ownership of purchased equipment. Covered equipment may be rented or purchased at the discretion of the department. In…

Rule 67:16:29:06 Rental payments applied to purchase. 67:16:29:06. Rental payments applied to purchase. When equipment is rented, the rental payments must be applied toward the allowable purchase price of the equipment. The department shall consider the equipment purchased when 1…

67:16:29:06.01. Conditions under which rental equipment no longer covered. Rental equipment is no longer covered when any of the following conditions exist: (1) The prescription for the equipment is not valid; (2) The equipment has been returned to the provider; or (3) The recipi…

Rule 67:16:29:07 Rate of payment. 67:16:29:07. Rate of payment. Payment for the purchase or the monthly rental of medical equipment covered under this chapter is limited to the lesser of the provider's usual and customary charge or the fee established on the department's fee sche…

Rule 67:16:29:08 Repealed. 67:16:29:08. Cost sharing. Repealed. Source: 14 SDR 46, effective September 28, 1987; 29 SDR 116, effective February 23, 2003; 42 SDR 51, effective October 13, 2015.

67:16:29:09. Billing requirements. Claims for medical equipment must be submitted at the provider's usual and customary charge. If it is the provider's custom to charge the general public for handling, delivery, and taxes, those charges may be included in the provider's usual and…

Rule 67:16:29:10 Utilization review. 67:16:29:10. Utilization review. Utilization review for medical equipment may be conducted during computerized claims processing and postpayment review. Source: 16 SDR 239, effective July 9, 1990. General Authority: SDCL 28-6-1. Law Implemente…

Rule 67:16:29:11 Claim requirements. 67:16:29:11. 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 67:16:29:12 Application of other chapters. 67:16:29:12. 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 67:16:31:01 Definitions. 67:16:31:01. Definitions. Terms used in this chapter mean: (1) "Roentgenographic," a record of the internal structures of the body made by passing X rays through the body to act on specially sensitized film; (2) "Severe hemodynamic compromise," sever…

Rule 67:16:31:02 Organ transplants covered. 67:16:31:02. Organ transplants covered. Kidney transplants and cornea transplants are covered for adults. Other nonexperimental organ transplant procedures are covered for adults if prior authorization is obtained from the department. S…

Rule 67:16:31:02.01 Liver transplants limited to certain centers. 67:16:31:02.01. Liver transplants limited to certain centers. Liver transplant services must be performed at a Medicare-approved transplant center or a transplant center approved by the Organ Procurement and Transp…

Rule 67:16:31:03 Repealed. 67:16:31:03. Conditions for covered heart transplants. Repealed. Source: 15 SDR 204, effective July 6, 1989; repealed, 37 SDR 53, effective September 23, 2010.

Rule 67:16:31:04 Heart transplants limited to certain centers. 67:16:31:04. Heart transplants limited to certain centers. Heart transplant services must be performed at a Medicare-approved transplant center. Source: 15 SDR 204, effective July 6, 1989; 16 SDR 234, effective July 2…

Rule 67:16:31:05 Individuals eligible for Medicare must apply to Medicare. 67:16:31:05. Individuals eligible for Medicare must apply to Medicare. Individuals eligible for Medicare must apply to Medicare for coverage of any proposed transplant. A decision by Medicare that a transp…

Rule 67:16:31:06 Transplants limited to human organs. 67:16:31:06. Transplants limited to human organs. Only human organs may be used for transplants covered under this chapter. Source: 15 SDR 204, effective July 6, 1989. General Authority: SDCL 28-6-1. Law Implemented: SDCL 28-6…

Rule 67:16:31:07 Expenses for transplant donors. 67:16:31:07. Expenses for transplant donors. Covered medical expenses for transplant donors are limited to the donor's hospitalization, physician, and laboratory fees. Source: 15 SDR 204, effective July 6, 1989. General Authority: …

Rule 67:16:31:08 Donated funds. 67:16:31:08. Donated funds. Money donated on behalf of an individual as the result of fund drives or other community fund-raising activities for the purpose of assisting with the costs associated with a transplant must be applied to the payment for…