South Dakota Administrative Code

Rule 67:16:40:01 Definitions. 67:16:40:01. Definitions. Terms used in this chapter mean: (1) "Activities of daily living," an individual's physical functions including the ability to bathe, dress, eat, toilet, and move; (2) "Care conference," a meeting of medical professionals sp…

Rule 67:16:40:02 Certain hospitals required to participate in care management. 67:16:40:02. Certain hospitals required to participate in care management. An acute care hospital which is a participating provider in the medical assistance program and has a unit which is exempt from…

Rule 67:16:40:03 Individuals subject to care management. 67:16:40:03. Individuals subject to care management. The following individuals are subject to care management: (1) A recipient, including a recipient who has a third-party resource which may be liable for the recipient's me…

Rule 67:16:40:04 Authorization for admission required. 67:16:40:04. Authorization for admission required. A hospital must receive authorization from the care manager before admitting any of the individuals specified in § 67:16:40:03 to one of the exempt units listed in § 67:16:40…

Rule 67:16:40:05 Procedure for admission to psychiatric and neonatal units when care manager not available. 67:16:40:05. Procedure for admission to psychiatric and neonatal units when care manager not available. If the admission is to a neonatal or psychiatric unit and the care m…

Rule 67:16:40:06 Hospital to supply medical documentation to support admission. 67:16:40:06. Hospital to supply documentation to support admission. Before the care manager authorizes care under this chapter, the hospital must provide the care manager with medical documentation wh…

Rule 67:16:40:07 Admission requirements -- Psychiatric care. 67:16:40:07. Admission requirements -- Psychiatric care. An individual's psychiatric care is a covered service under this chapter if the hospital received authorization for the admission under § 67:16:40:04 and the foll…

Rule 67:16:40:08 Admission requirements -- Neonatal intensive care. 67:16:40:08. Admission requirements -- Neonatal intensive care. Neonatal intensive care services are considered covered services if a neonatologist orders the admission, there is a comprehensive history and physi…

Rule 67:16:40:09 Admission requirements -- Rehabilitation care. 67:16:40:09. Admission requirements -- Rehabilitation care. An individual's admission to a rehabilitation unit is a covered service if the hospital received authorization for the admission under § 67:16:40:04 and the…

Rule 67:16:40:09.01 Admission requirements -- Long-term care hospital unit. 67:16:40:09.01. Admission requirements -- Long-term care hospital unit. Admissions to a long-term care hospital unit are limited to transfers from a general acute care hospital and must be more cost effec…

Rule 67:16:40:10 Care plan requirements. 67:16:40:10. Care plan requirements. A facility must prepare a care plan for each individual admitted under the provisions of this chapter. The care plan must contain at least the following information: (1) A description of the medically n…

Rule 67:16:40:11 Psychiatric admission requires psychiatric evaluation. 67:16:40:11. Psychiatric admission requires psychiatric evaluation. Within 24 hours after an individual is admitted for inpatient psychiatric care, the hospital must have a psychiatrist complete a psychiatric…

Rule 67:16:40:12 Hospital to supply information to care manager. 67:16:40:12. Hospital to supply information to care manager. Within 24 hours after the care manager's request, a facility must provide or make available the active or closed admission records of those individuals su…

Rule 67:16:40:13 Care manager to review and approve the need for continued stay. 67:16:40:13. Care manager to review and approve the need for continued stay. After the care manager approves an admission, the care manager shall review the individual's medical records to determine …

Rule 67:16:40:14 Requirements for continued stay -- Psychiatric care. 67:16:40:14. Requirements for continued stay -- Psychiatric care. An individual's continuous and uninterrupted stay in inpatient psychiatric care is a covered service if the care manager determines that the fol…

Rule 67:16:40:15 Requirements for continued stay -- Rehabilitation care. 67:16:40:15. Requirements for continued stay -- Rehabilitation care. An individual's continued stay in a rehabilitation unit is a covered service under this chapter if the individual demonstrates weekly impr…

Rule 67:16:40:16 Requirements for continued stay -- Neonatal intensive care. 67:16:40:16. Requirements for continued stay -- Neonatal intensive care. Continued stay in a neonatal intensive care unit is a medically necessary covered service only if at least one of the conditions s…

Rule 67:16:40:16.01 Requirements for continued stay -- Long-term care hospital unit. 67:16:40:16.01. Requirements for continued stay -- Long-term care hospital unit. An individual's continued stay in a long-term care hospital unit is a covered service under this chapter if the in…

Rule 67:16:40:17 Criteria for terminating coverage -- Psychiatric care. 67:16:40:17. Criteria for terminating coverage -- Psychiatric care. An individual's psychiatric care becomes a noncovered service when the care manager determines that the conditions of § 67:16:40:07 are no l…

Rule 67:16:40:18 Criteria for terminating coverage -- Rehabilitation. 67:16:40:18. Criteria for terminating coverage -- Rehabilitation. An individual's care in a rehabilitation unit becomes a noncovered service if the care manager determines that the individual meets any of the f…

Rule 67:16:40:19 Criteria for terminating coverage -- Neonatal intensive care. 67:16:40:19. Criteria for terminating coverage -- Neonatal intensive care. An infant's care in a neonatal intensive care unit becomes a noncovered service if the infant meets all of the following crite…

Rule 67:16:40:20 Criteria for terminating coverage -- Long-term care hospital unit. 67:16:40:20. Criteria for terminating coverage -- Long-term care hospital unit. An individual's care in a long-term care hospital unit becomes a noncovered service if the care manager determines t…

67:16:41:01. Definitions. As used in this chapter: (1) "Certified social worker - private, independent practice" means an individual certified under SDCL 36-26-17; (2) "Certified social worker - private, independent practice candidate" means an individual who is licensed as a cer…

67:16:41:02. Mental health service requirements. To be covered under this chapter, mental health services are limited to services that are established in this chapter and meet the following requirements: (1) There must be a diagnostic assessment prepared by a mental health provid…

Rule 67:16:41:03 Mental health provider. 67:16:41:03. Mental health provider. A mental health provider must be a psychologist, a licensed professional counselor - mental health, a licensed professional counselor working toward a mental health designation, a clinical nurse special…

67:16:41:04. Diagnostic assessment requirements. A diagnostic assessment must be completed within 30 days of the recipient's first face-to-face or telehealth visit with a mental health provider. On-going assessment and identification of changes in the recipient's needs and streng…

67:16:41:04.01. Diagnostic assessment components. A diagnostic assessment must include: (1) A face-to-face or telehealth interview with the recipient; (2) Identification of the strengths of the recipient and the recipient's family, if appropriate; previous periods of success and …

Rule 67:16:41:05 Mental disorder diagnosis codes -- Limits. 67:16:41:05. Mental disorder diagnosis codes -- Limits. For purposes of this chapter, mental disorder diagnosis codes are limited to the diagnosis codes listed on the department's billing guidance website and contained i…

67:16:41:06. Treatment plan requirements. A mental health provider shall develop a treatment plan for each recipient who is receiving medically necessary, covered mental health treatment based on a primary diagnosis of a mental disorder. The plan must be relevant to the diagnosis…

Rule 67:16:41:07 Treatment plan reviews. 67:16:41:07. Treatment plan reviews. As long as mental health services continue, the mental health provider must review the recipient's treatment plan at least semiannually with the first review completed no later than six months from the …

Rule 67:16:41:08 Clinical record requirements. 67:16:41:08. Clinical record requirements. The mental health provider must maintain the recipient's clinical record. In addition to the record requirements contained in chapter 67:16:34, the recipient's clinical record must contain t…

67:16:41:09. Covered mental health services -- Limits -- Payments. Payment for mental health services is the lesser of the provider's usual and customary charge or the fee listed on the department's fee schedule website. If no fee is listed, payment is 40 percent of the provider'…

67:16:41:10. Noncovered services. The department does not cover and the provider may not submit a claim for: (1) Mental health services not defined in § 67:16:41:01; (2) Mental health treatment provided without the recipient physically present in a face-to-face session with the m…

Rule 67:16:41:11 Prior authorization. 67:16:41:11. Prior authorization. A mental health provider must have prior authorization from the department before providing any treatment listed in § 67:16:41:09 which will exceed the limits established in this chapter. Authorization is bas…

Rule 67:16:41:12 Repealed. 67:16:41:12. Handwritten originals required. Repealed. Source: 22 SDR 6, effective July 26, 1995; 46 SDR 50, effective October 10, 2019.

Rule 67:16:41:13 Claim requirements. 67:16:41:13. 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…

67:16:41:14. Billing requirements. The following requirements apply to services billed under this chapter: (1) Each claim must contain the medical assistance provider identification number of the individual delivering the service; (2) A claim may not be submitted for a diagnostic…

Rule 67:16:41:15 Utilization review. 67:16:41:15. Utilization review. Utilization review may be conducted on the following levels: (1) Computerized claim processing; (2) Postpayment review; and (3) Peer review. A peer review entity appointed by the department shall review claims …

Rule 67:16:41:16 Repealed. 67:16:41:16. Cost sharing. Repealed. Source: 22 SDR 6, effective July 26, 1995; 31 SDR 191, effective June 8, 2005; 42 SDR 51, effective October 13, 2015.

Rule 67:16:41:17 Application of other chapters. 67:16:41:17. 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 if applicable, 67:…

Rule 67:16:42:01 Definitions. 67:16:42:01. Definitions. Terms used in this chapter mean: (1) "Enteral nutritional therapy," nutritional therapy by way of the small intestine through nasogastric, jejunostomy, or gastrostomy tubes; (2) "Nutritional supplement," specialized formulas…

Rule 67:16:42:02 Repealed. 67:16:42:02. Enteral nutritional therapy and nutritional supplements for individual under 21 years of age. Repealed. Source: 17 SDR 37, effective September 11, 1990; 17 SDR 184, effective June 6, 1991; 17 SDR 200, effective July 1, 1991; 18 SDR 209, eff…

Rule 67:16:42:03 Repealed. 67:16:42:03. Enteral nutritional therapy for individual 21 years of age and older. Repealed. Source: 22 SDR 32, effective September 11, 1995; 40 SDR 122, effective January 7, 2014; 40 SDR 122, effective January 8, 2014; 44 SDR 94, effective December 4, …

Rule 67:16:42:04 Repealed. 67:16:42:04. Enteral nutritional therapy for individual 21 years of age and older -- Prior authorization required. Repealed. Source: 22 SDR 32, effective September 11, 1995; 35 SDR 49, effective September 10, 2008; 40 SDR 122, effective January 7, 2014;…

Rule 67:16:42:05 Repealed. 67:16:42:05. Parenteral nutritional therapy. Repealed. Source: 22 SDR 32, effective September 11, 1995; 40 SDR 122, effective January 7, 2014; 40 SDR 122, effective January 8, 2014; 44 SDR 94, effective December 4, 2017.

Rule 67:16:42:06 Repealed. 67:16:42:06. Parenteral nutritional therapy -- Prior authorization required. Repealed. Source: 17 SDR 37, effective September 11, 1990; 17 SDR 184, effective June 6, 1991; 17 SDR 200, effective July 1, 1991; 18 SDR 209, effective June 23, 1992; transfer…

Rule 67:16:42:07 Nutritional therapy and nutritional supplements -- Limits. 67:16:42:07. Nutritional therapy and nutritional supplements -- Limits. Covered enteral therapy, oral nutrition, electrolyte replacement, and parenteral therapy services and supplies are contained on the …

67:16:42:08. Services not covered. Services not covered under this chapter include: (1) Nutritional supplementation for individuals 21 years of age or older, unless the recipient has a diagnosis consistent with inborn errors of metabolism; and (2) Nutritional supplementation for …

Rule 67:16:42:09 Rate of payment. 67:16:42:09. Rate of payment. Payment for nutritional items and supplies is the lesser of the provider's usual and customary charge or the applicable fee established on the department's fee schedule website. If no fee is specified for nutritional…

Rule 67:16:42:10 Repealed. 67:16:42:10. Cost sharing. Repealed. Source: 22 SDR 32, effective September 11, 1995; 42 SDR 51, effective October 13, 2015.