South Dakota Administrative Code

Rule 67:16:37:04 Service restrictions. 67:16:37:04. Service restrictions. A service provided under this chapter must meet the following conditions: (1) The service must be medically necessary. Evidence establishing the medical necessity must be maintained in the individual's reco…

Rule 67:16:37:04.01 Covered services -- Limits. 67:16:37:04.01. Covered services -- Limits. Services covered under this chapter are limited to the following: (1) Psychological services under § 67:16:37:06; (2) Physical therapy services; (3) Occupational therapy services; (4) Spee…

Rule 67:16:37:05 Required licensure or certification requirements for service provider. 67:16:37:05. Required licensure or certification requirements for service provider. An individual providing services under this chapter shall meet the following licensure or certification requ…

Rule 67:16:37:06 Covered psychological services. 67:16:37:06. Covered psychological services. Psychological services are limited to the following: (1) Integrated screening, assessment, and evaluation; (2) Individual therapy: (3) Group therapy; (4) Parent or guardian group therapy…

Rule 67:16:37:07 Repealed. 67:16:37:07. Covered physical therapy services. Repealed. Source: 18 SDR 78, effective November 4, 1991; repealed, 18 SDR 224, effective July 13, 1992.

Rule 67:16:37:08 Repealed. 67:16:37:08. Covered occupational therapy services. Repealed. Source: 18 SDR 78, effective November 4, 1991; repealed, 18 SDR 224, effective July 13, 1992.

Rule 67:16:37:09 Repealed. 67:16:37:09. Covered speech therapy services. Repealed. Source: 18 SDR 78, effective November 4, 1991; repealed, 18 SDR 224, effective July 13, 1992.

Rule 67:16:37:10 Repealed. 67:16:37:10. Covered audiology services. Repealed. Source: 18 SDR 78, effective November 4, 1991; repealed, 18 SDR 224, effective July 13, 1992. Rule 67:16:37:10.01 Requirements for supervising speech- language pathologist. 67:16:37:10.01. Requirements …

Rule 67:16:37:10.01 Requirements for supervising speech- language pathologist. 67:16:37:10.01. Requirements for supervising speech-language pathologist. If speech therapy services are provided by a speech-language pathology assistant, the supervising speech-language pathologist m…

Rule 67:16:37:11 Covered nursing services. 67:16:37:11. Covered nursing services. Nursing services are limited to the following services provided to treat a chronic medical illness: (1) Nursing evaluation or assessment, which includes observation of recipients with chronic medica…

Rule 67:16:37:12 Rate of payment. 67:16:37:12. Rate of payment. Payment for services under this chapter is limited to the lesser of the federal share of the provider's usual and customary charge or the federal share of the rate negotiated between the department of education and t…

Rule 67:16:37:13 Utilization review. 67:16:37:13. Utilization review. Utilization review for school district services may be conducted on the following levels: (1) Computerized claims processing; (2) Postpayment review; and (3) Peer review. Source: 18 SDR 78, effective November 4…

Rule 67:16:37:14 Billing requirements. 67:16:37:14. Billing requirements. A school district submitting a claim for covered services under this chapter must submit the claim at its usual and customary charge. The school district must submit the claim when the service is listed in …

Rule 67:16:37:15 Claim requirements. 67:16:37:15. 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 67:16:37:16 Application of other chapters. 67:16:37:16. 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: 18 SDR 78,…

67:16:38:01. Reserved. Repealed.

67:16:38:02. Reserved. Repealed.

67:16:38:03. Reserved. Repealed.

67:16:38:04. Reserved. Repealed.

67:16:38:05. Reserved. Repealed.

67:16:38:06. Reserved. Repealed.

67:16:38:07. Reserved. Repealed.

67:16:38:08. Reserved. Repealed.

67:16:38:09. Reserved. Repealed.

67:16:38:10. Definitions. Repealed. Source: 18 SDR 162, effective April 2, 1992; 49 SDR 21, effective September 12, 2022.

67:16:38:11. Requirements for covered case management services. Repealed. Source: 18 SDR 162, effective April 2, 1992; 49 SDR 21, effective September 12, 2022.

67:16:38:12. Covered case management services -- Limits. Repealed. Source: 18 SDR 162, effective April 2, 1992; 49 SDR 21, effective September 12, 2022.

67:16:38:13. Services not covered. Repealed. Source: 18 SDR 162, effective April 2, 1992; 49 SDR 21, effective September 12, 2022.

67:16:38:14. Payment and procedure codes for covered services. Repealed. Source: 18 SDR 162, effective April 2, 1992; 49 SDR 21, effective September 12, 2022.

67:16:38:15. Modifier code required. Repealed. Source: 18 SDR 162, effective April 2, 1992; 49 SDR 21, effective September 12, 2022.

67:16:38:16. Billing requirements. Repealed. Source: 18 SDR 162, effective April 2, 1992; 49 SDR 21, effective September 12, 2022.

67:16:38:17. Claim requirements. Repealed. Source: 18 SDR 162, effective April 2, 1992; 49 SDR 21, effective September 12, 2022.

67:16:38:18. Application of other chapters. Repealed. Source: 18 SDR 162, effective April 2, 1992; 49 SDR 21, effective September 12, 2022.

Rule 67:16:39:01 Definitions. 67:16:39:01. Definitions. As used in this chapter: (1) "Designated covering provider," means another physician at the primary care provider's clinic who has an arrangement with a primary care provider to act as the recipient's primary care provider w…

Rule 67:16:39:02 Individuals required to participate. 67:16:39:02. Individuals required to participate. (1) An individual shall participate in the primary care provider program if the individual is: (a) Covered under subdivision 67:46:01:02(1); (b) At least 19 years old and cover…

Rule 67:16:39:03 Effective dates of program. 67:16:39:03. Effective dates of program. The provisions of this chapter become effective the first full calendar month after the recipient chooses a PCP or the department assigns a PCP to the recipient. Source: 20 SDR 135, effective Fe…

Rule 67:16:39:04 Recipient responsible for payment of noncovered services. 67:16:39:04. Recipient responsible for payment of noncovered services. Medical expenses incurred outside the rules of this chapter are considered noncovered services and payment for those services is the r…

Rule 67:16:39:05 Provider requirements. 67:16:39:05. Provider requirements. A primary care provider must: (1) Have an approved and signed medical assistance provider agreement with the department under chapter 67:16:33; (2) Have an approved and signed primary care provider addend…

Rule 67:16:39:06 Choice of primary care provider. 67:16:39:06. Choice of primary care provider. An individual required to participate in the primary care provider program must select a primary care provider from a list of participating primary care providers. The department shall…

Rule 67:16:39:07 Change in primary care provider. 67:16:39:07. Change in primary care provider. The primary care provider selection remains in effect until: (1) The recipient submits a written or verbal request for a provider change to the department during the recipient's annual…

Rule 67:16:39:08 Primary care provider to provide service or refer recipient for service. 67:16:39:08. Primary care provider to provide service or refer recipient for service. Medically necessary covered services provided under the primary care provider program must be provided b…

Rule 67:16:39:09 Use of medical assistance identification card required. 67:16:39:09. Use of medical assistance identification card required. For a service to be covered, a recipient must present the recipient's medical assistance identification card to a provider before obtainin…

67:16:39:10. Primary care provider program services. Primary care provider program services include the following medically necessary covered services: (1) Physician services listed in chapter 67:16:02; (2) Inpatient and outpatient hospital services listed in chapter 67:16:03; (3…

Rule 67:16:39:11 Exempt services. 67:16:39:11. Exempt services. The following medically necessary covered services are exempt from this chapter: (1) Family planning services; (2) Emergency services as defined in chapter 67:16:01; (3) Dental services listed in chapter 67:16:06; (4…

Rule 67:16:39:12 Repealed. 67:16:39:12. Community mental health centers -- Physician-directed services. Repealed. Source: 20 SDR 135, effective February 22, 1994; repealed, 30 SDR 115, effective February 4, 2004.

67:16:39:13. Billing requirements. Claims submitted under this chapter must meet the following billing requirements: (1) Physician services must follow the billing requirements contained in chapter 67:16:02; (2) Inpatient and outpatient hospital services must follow the billing r…

Rule 67:16:39:14 Repealed. 67:16:39:14. Billing requirements -- Pharmacy claims. Repealed. Source: 20 SDR 135, effective February 22, 1994; 26 SDR 168, effective July 1, 2000; repealed, 30 SDR 115, effective February 4, 2004.

67:16:39:15. Claim requirements. Claims submitted under this chapter must meet the following claim requirements: (1) Physician services must follow the claim requirements contained in chapter 67:16:02; (2) Inpatient and outpatient hospital services must follow the claim requireme…

67:16:39:16. Claim requirements -- Pharmacy claims. Repealed. Source: 20 SDR 135, effective February 22, 1994; 26 SDR 168, effective July 1, 2000; 30 SDR 115, effective February 4, 2004.

67:16:39:17. Cost share exemption. Repealed. Source: 37 SDR 53, effective September 23, 2010; 51 SDR 13, effective August 12, 2024.