South Dakota Administrative Code

Rule 67:16:31:09 Rate of payment. 67:16:31:09. Rate of payment. Payment for services covered under this chapter is limited to the amounts allowed in chapters 67:16:02 and 67:16:03. Source: 15 SDR 204, effective July 6, 1989; 16 SDR 234, effective July 2, 1990. General Authority: …

Rule 67:16:31:10 Billing requirements. 67:16:31:10. Billing requirements. A claim submitted under this chapter must be submitted at the provider's usual and customary charge and must contain the appropriate procedures codes contained in chapters 67:16:02 and 67:16:03. Source: 16 …

Rule 67:16:31:11 Utilization review. 67:16:31:11. Utilization review. Utilization review for organ transplants may be conducted on the following levels: (1) Computerized claims processing; (2) Postpayment review; and (3) Peer review. Source: 16 SDR 234, effective July 2, 1990. Ge…

Rule 67:16:31:12 Application of other chapters. 67:16:31:12. 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 67:16:33:01 Reserved. 67:16:33:01. Reserved.

Rule 67:16:33:02 Participating provider. 67:16:33:02. Participating provider. To receive reimbursement for covered medical services which are medically necessary and which are provided to eligible recipients, a provider must have a provider agreement with the department. The agre…

Rule 67:16:33:03 Provider agreements limited to providers who provide a covered service. 67:16:33:03. Provider agreements limited to providers who provide a covered service. The department may enter into a provider agreement only with those providers who provide a service covered…

Rule 67:16:33:04 Duration of agreement. 67:16:33:04. Duration of agreement. A provider agreement remains in effect until one of the following occurs: (1) The agreement expires; (2) The provider fails to comply with conditions of the signed provider agreement or conditions of part…

Rule 67:16:33:05 Individuals providing services under another provider's agreement. 67:16:33:05. Individuals providing services under another provider's agreement. An individual who does not have a provider agreement but who furnishes a covered service to a recipient under anothe…

Rule 67:16:33:06 Disclosure requirements. 67:16:33:06. Disclosure requirements. A provider must disclose information on ownership, control interest, and convictions as required by 42 C.F.R. § 455, Subpart B (October 1, 1989). Source: 17 SDR 4, effective July 16, 1990. General Aut…

Rule 67:16:33:07 Sale or transfer of entity. 67:16:33:07. Sale or transfer of entity. A participating provider who sells or transfers ownership or control of the entity must give the department written notice of the pending sale or transfer at least 30 days before the effective d…

Rule 67:16:33:08 Licensing or certification changes. 67:16:33:08. Licensing or certification changes. The participating provider must notify the department in writing of any change in the provider's licensing or certification status. Notification must be made within ten days afte…

Rule 67:16:33:09 Application of chapter. 67:16:33:09. 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 67:16:34:01 Reserved. 67:16:34:01. Reserved.

Rule 67:16:34:02 Maintenance of medical and financial records. 67:16:34:02. Maintenance of medical and financial records. Providers must keep legible medical and fiscal records that fully justify and disclose the extent of services provided and the billings made to the department…

Rule 67:16:34:03 Required medical records. 67:16:34:03. Required medical records. A provider must maintain a medical record on each recipient, which discloses the extent of services furnished under this article. Each page of the record must name or otherwise identify the recipien…

Rule 67:16:34:04 Required financial records. 67:16:34:04. Required financial records. Providers must maintain an accounting system pursuant to generally accepted accounting practices which enables the provider to clearly identify the cost of services and other expenses of operati…

Rule 67:16:34:05 Record retention. 67:16:34:05. Record retention. Medical and financial records must be retained for at least six years after the last claim is paid or denied. Records may not be destroyed if an audit or investigation is pending. Medical and financial records must…

Rule 67:16:34:06 Record retention -- Change of ownership. 67:16:34:06. Record retention -- Change of ownership. If there is a change of ownership of a provider entity, facility, or practice, the seller is responsible for maintaining and ensuring access to records generated prior …

Rule 67:16:34:07 Record retention -- Provider withdrawal or termination. 67:16:34:07. Record retention -- Provider withdrawal or termination. If a provider withdraws or is terminated from the medical services program, records developed during program participation must be retaine…

Rule 67:16:34:08 Access to records. 67:16:34:08. Access to records. Providers must grant the department, the Office of the Attorney General, the Department of Health, the Department of Human Services, and the U.S. Department of Health and Human Services access during regular busi…

Rule 67:16:34:09 Application of chapter. 67:16:34:09. Application of chapter. The rules in this chapter apply to all enrolled providers for services provided to medical assistance program recipients. Source: 17 SDR 184, effective June 6, 1991; 46 SDR 50, effective October 10, 201…

Rule 67:16:35:01 Definitions. 67:16:35:01. Definitions. Terms used in this chapter mean: (1) "Adjustment/void claim form," a form that is used to adjust or void a previously paid claim; (2) "Cross-over claim form," a form used to record the Medicare co-insurance and deductible pa…

Rule 67:16:35:02 Verification of eligibility before claim submitted. 67:16:35:02. Verification of eligibility before claim submitted. Before a provider submits a claim, the provider must verify an individual's eligibility for the medical assistance program by requesting the indiv…

67:16:35:03. Claims limited to items and services covered under article. A provider may submit claims only for those supplies and services that the provider knows, or should have known, are covered under this article. A provider, other than a school district, may not submit claim…

Rule 67:16:35:04 Time limits for submission of claims. 67:16:35:04. Time limits for submission of claims. The department must receive a provider's completed claim form within six months following the month the service was provided. This time limit may be waived or extended only i…

Rule 67:16:35:05 Electronic media provider agreement. 67:16:35:05. Electronic media provider agreement. Providers submitting claims by electronic media must have a signed electronic media agreement with the department before submitting claims. Source: 17 SDR 4, effective July 16,…

Rule 67:16:35:06 Medical assistance cross-over claim requirements. 67:16:35:06. Medical assistance cross-over claim requirements. A cross-over claim may be submitted to the department if the provider's claim to Medicare did not trigger an automatic payment of the deductible or co…

Rule 67:16:35:07 Adjustment/void claims. 67:16:35:07. Adjustment/void claims. A provider may have a previously paid claim adjusted or voided by completing and submitting a new claim to the Department coded as an adjustment or void. Claim forms may be submitted electronically. Sou…

Rule 67:16:35:08 Requests for reimbursement -- Certification. 67:16:35:08. Requests for reimbursement -- Certification. The provider or the provider's representative must sign the claim as a certification of the truth and accuracy of the claim. The provider's name, not the name o…

Rule 67:16:35:09 Use of rubber stamps for claim information. 67:16:35:09. Use of rubber stamps for claim information. The use of rubber stamps containing claim information is acceptable only if the imprint is legible. Source: 17 SDR 4, effective July 16, 1990. General Authority: …

Rule 67:16:35:10 Claim substantiation. 67:16:35:10. Claim substantiation. At the department's request, a provider must furnish information needed to substantiate a claim being processed, a claim being reviewed for determination of payment, or a claim under postpayment review. Sou…

Rule 67:16:35:11 Repealed. 67:16:35:11. Claim forms and copies. Repealed. Source: 17 SDR 4, effective July 16, 1990; repealed, 40 SDR 122, effective January 7, 2014.

Rule 67:16:35:12 Pended claims. 67:16:35:12. Pended claims. The department may pend a claim for any of the following general classes of reasons: (1) The claim was submitted with erroneous, incomplete, or missing information; (2) The information on the claim does not match the sta…

Rule 67:16:35:13 Denied claims. 67:16:35:13. Denied claims. The department may deny a claim for any of the following reasons: (1) The service claimed was not medically necessary; (2) The claim is a duplicate of a prior paid claim; (3) Third-party liability exists; (4) The claim c…

Rule 67:16:35:14 Remittance advice. 67:16:35:14. Remittance advice. The provider must reconcile the remittance advice with the patient's records. The department shall send a warrant with the remittance advice when the amount of a check is indicated on the remittance advice. The p…

Rule 67:16:35:15 Claim submission and resubmission limits. 67:16:35:15. Claim submission and resubmission limits. A participating provider may not submit a claim for a provider who has been excluded or terminated from the medical assistance program or who otherwise does not meet …

Rule 67:16:35:16 Application of chapter. 67:16:35:16. 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 67:16:36:01 Definitions. 67:16:36:01. Definitions. Terms used in this chapter mean: (1) "Assisted living center," a facility as defined in SDCL subdivision 34-12-1.1(2); (2) "Continuous home care day," a category of care as defined in 42 C.F.R. § 418.302 (as amended to Janua…

Rule 67:16:36:02 Eligibility requirements -- Individual. 67:16:36:02. Eligibility requirements -- Individual. An individual is eligible for hospice services if the following conditions are met: (1) The individual has a written statement from a physician or other licensed practiti…

Rule 67:16:36:03 Eligibility requirements -- Provider. 67:16:36:03. Eligibility requirements -- Provider. A facility is eligible for reimbursement for hospice services if the following conditions are met: (1) The facility has a signed provider agreement with the department; and (…

Rule 67:16:36:04 Covered services -- Limits. 67:16:36:04. Covered services -- Limits. Hospice services are limited to the following: (1) Routine home care provided in a recipient's place of residence, skilled nursing facility, ICF-IID, swing bed, assisted living center, residenti…

Rule 67:16:36:05 Reimbursement for room and board. 67:16:36:05. Reimbursement for room and board. A recipient's room and board is covered through the hospice benefit under the following circumstances: (1) If a recipient is receiving routine home care in an inpatient hospice; or (…

Rule 67:16:36:06 Notice requirements. 67:16:36:06. Notice requirements. The hospice provider shall submit notice on a form designated by the department if a recipient elects or revokes the hospice benefit, dies, or discharges from the hospice provider's care. Notice must be sent …

Rule 67:16:36:07 Claim requirements. 67:16:36:07. Claim requirements. A claim for services provided under the provisions of this chapter must follow the requirements established in § 67:16:03:14. The hospice facility shall submit a separate claim for each individual receiving hos…

Rule 67:16:36:08 Utilization review. 67:16:36:08. Utilization review. Utilization review of hospice services may be conducted on three levels: (1) Claims review; (2) Auditing; and (3) Post-payment review. Source: 37 SDR 127, effective December 27, 2010. General Authority: SDCL 28…

Rule 67:16:36:09 Application of other chapters. 67:16:36:09. Application of other chapters. In addition to the rules contained in this chapter, providers and recipients must meet the requirements of article 67:45 and chapters 67:16:01, 67:16:26, 67:16:33, 67:16:34, and 67:16:35. …

Rule 67:16:37:01 Definitions. 67:16:37:01. Definitions. Terms used in this chapter mean: (1) "Care plan," a written plan for a particular individual which outlines medically necessary health services and the duration of those services, including an individual education program (I…

Rule 67:16:37:02 School district may be medical assistance provider. 67:16:37:02. School district may be medical assistance provider. A school district may be a medical assistance provider if the following conditions are met: (1) The school district provides any of the services c…

Rule 67:16:37:03 Care plan required. 67:16:37:03. Care plan required. The school district must have a care plan for each individual receiving medical services under this chapter. Professionals involved in the child's care must prepare the care plan. The care plan may not be effec…