South Dakota Administrative Code

Rule 67:16:42:11 Limit on costs. 67:16:42:11. Limit on costs. If the recipient requires regular or routine medical services in addition to the nutritional therapy or nutritional supplements provided under this chapter, the cost of all the services provided in the home may not exc…

Rule 67:16:42:12 Billing requirements. 67:16:42:12. Billing requirements. A provider submitting a claim for reimbursement under this chapter must submit the claim at the provider's usual and customary charge. Costs of professional intervention services, such as nursing and dietar…

Rule 67:16:42:13 Claim requirements. 67:16:42:13. Claim requirements. A claim for nutritional items and supplies 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 reci…

Rule 67:16:42:14 Utilization review. 67:16:42:14. Utilization review. The department may conduct utilization reviews of nutritional therapy and nutritional supplements during computerized claims processing and postpayment review. Source: 22 SDR 32, effective September 11, 1995. G…

Rule 67:16:42:15 Application of other chapters. 67:16:42:15. 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 if applicable, 67:…

Rule 67:16:43:01 Definitions. 67:16:43:01. Definitions. Terms used in this chapter mean: (1) "Care management," the monitoring of admissions to the medically complex program to assure the medical necessity of the admission, monitor the need for a continued stay in the program, an…

Rule 67:16:43:02 Children subject to care management. 67:16:43:02. Children subject to care management. A child who is eligible for medical assistance and is in need of complex medical care is subject to care management. Source: 23 SDR 2, effective July 15, 1996; 26 SDR 168, effe…

Rule 67:16:43:03 Authorization for admission required. 67:16:43:03. Authorization for admission required. A facility must have authorization from the care manager before admitting a child to a medically complex program. The care manager shall use the criteria contained in § 67:16…

Rule 67:16:43:04 Admission requirements. 67:16:43:04. Admission requirements. Admission to a medically complex program is a covered service if the following criteria are met: (1) Medical documentation substantiates that the service is medically necessary. Medical documentation in…

Rule 67:16:43:05 Care plan requirements. 67:16:43:05. Care plan requirements. The interdisciplinary team must prepare a care plan for each child admitted under the provisions of this chapter. The care plan must contain at least the following information: (1) A description of the …

Rule 67:16:43:06 Care manager to review and approve the need for continued stay. 67:16:43:06. Care manager to review and approve the need for continued stay. After the care manager approves an admission, the care manager shall review the child's medical records to determine wheth…

Rule 67:16:43:07 Criteria for discharge. 67:16:43:07. Criteria for discharge. A child's care in the medically complex program is no longer a covered service when the care manager determines that the child's condition has stabilized and the criteria contained in § 67:16:43:04 are …

Rule 67:16:43:08 Rate of payment -- Limits. 67:16:43:08. Rate of payment -- Limits. Payment is subject to the following restrictions: (1) Payment is limited to days the child is actually in the facility; (2) Payment is made for the day of admission but not the day of discharge; (…

Rule 67:16:43:09 Claim requirements. 67:16:43:09. Claim requirements. A claim for services provided under this chapter must be submitted on a form which contains the following information: (1) The child's full name; (2) The child's medical assistance identification number from th…

Rule 67:16:43:10 Billing requirements 67:16:43:10. Billing requirements. When submitting a claim under this chapter, a facility may bill only for the number of days a child is actually in the facility. Source: 23 SDR 2, effective July 15, 1996. General Authority: SDCL 28-6-1. Law…

Rule 67:16:43:11 Application of other chapters. 67:16:43:11. 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, 67:16:35, and 67:16:39. Source: …

67:16:44:01. Definitions. As used in this article: (1) "Federally qualified health center" means an entity that meets the requirements set forth in 42 C.F.R. § 405.2401, as amended to November 23, 2018; (2) "Provider" means a federally qualified health center or a rural health cl…

Rule 67:16:44:02 Covered services. 67:16:44:02. Covered services. Services covered under this chapter are limited to services that meet the following criteria: (1) Medically necessary services covered under chapters 67:16:01, 67:16:02, 67:16:06, 67:16:11, 67:16:12, 67:16:41, and …

Rule 67:16:44:03 Repealed. 67:16:44:03. Covered services -- Mental health services. Repealed. Source: 23 SDR 109, effective January 5, 1997; 46 SDR 50, effective October 10, 2019.

Rule 67:16:44:04 Repealed. 67:16:44:04. Use of Medicare manuals. Repealed. Source: 23 SDR 109, effective January 5, 1997; 46 SDR 50, effective October 10, 2019.

Rule 67:16:44:05 Required cost reports. 67:16:44:05. Required cost reports. A provider must submit to the Department of Social Services, Office of Provider Reimbursement and Audits, a completed copy of the provider's cost report showing the actual costs incurred during the report…

Rule 67:16:44:06 Rate of payment. 67:16:44:06. Rate of payment. Payment is made at an all-inclusive rate for each visit for covered services. The department follows the standards established by the Medicare, Medicaid, and State Children's Health Insurance Program Benefits Improve…

Rule 67:16:44:07 Payment limitations. 67:16:44:07. Payment limitations. Payments at an all-inclusive rate to a federally qualified health center or rural health clinic are subject to the following limitations: (1) Encounters with more than one health professional and multiple enc…

Rule 67:16:44:08 Repealed. 67:16:44:08. Cost sharing. Repealed. Source: 23 SDR 109, effective January 5, 1997; 24 SDR 11, effective August 4, 1997; 31 SDR 191, effective June 8, 2005; 33 SDR 44, effective September 20, 2006; 42 SDR 51, effective October 13, 2015.

Rule 67:16:44:09 Billing requirements. 67:16:44:09. Billing requirements. A claim submitted under this chapter must be submitted at the provider's usual and customary charge. Source: 23 SDR 109, effective January 5, 1997; 46 SDR 50, effective October 10, 2019. General Authority: …

Rule 67:16:44:10 Claim requirements. 67:16:44:10. 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 67:16:44:11 Repealed. 67:16:44:11. Audits -- Appeal provisions. Repealed. Source: 23 SDR 109, effective January 5, 1997; 26 SDR 168, effective July 1, 2000; 46 SDR 50, effective October 10, 2019.

Rule 67:16:44:12 Repealed. 67:16:44:12. Cost settlement. Repealed. Source: 23 SDR 109, effective January 5, 1997; repealed, 33 SDR 44, effective September 20, 2006.

Rule 67:16:44:13 Utilization review. 67:16:44:13. Utilization review. Utilization review for federally qualified health center or rural health clinic services may be conducted on the following levels: (1) Computerized claims processing; (2) Postpayment review; and (3) Peer review…

Rule 67:16:44:14 Application of other chapters. 67:16:44:14. 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. Source: …

67:16:46:01. Definitions. As used in this chapter: (1) "Diabetes self-management training" means a program delivered on an outpatient basis and designed to educate a person with diabetes in the self-management of diabetes. Source: 28 SDR 84, effective December 20, 2001; 49 SDR 21…

67:16:46:02. Eligibility requirements -- Providers. A diabetes self-management training provider may receive reimbursement for services covered under this chapter if the provider is a participating provider in the medical assistance program and the program is recognized by the Am…

67:16:46:03. Eligibility requirements -- Individuals. An individual is eligible to participate in diabetes self-management training, if the individual is not institutionalized, the training is conducted by a provider eligible under § 67:16:46:02, the individual has not previously…

67:16:46:04. Limit on hours of service. Diabetes self-management training is limited to: (1) Ten hours of initial training; and (2) Two hours per year of follow-up training. The department shall authorize training that exceeds the limits set in this section, before the services a…

Rule 67:16:46:05 Rate of payment. 67:16:46:05. Rate of payment. Payment for services covered under the provisions of this chapter is limited to the procedure codes established on the department's fee schedule website. The services and associated rates of payment are subject to re…

Rule 67:16:46:06 Claim requirements. 67:16:46:06. Claim requirements. A claim submitted under this chapter must be submitted at the provider's usual and customary charge and must contain the applicable procedure codes contained in § 67:16:46:05. The claim for services must be sub…

Rule 67:16:46:07 Repealed. 67:16:46:07. Cost sharing. Repealed. Source: 28 SDR 84, effective December 20, 2001; 31 SDR 191, effective June 8, 2005: 37 SDR 53, effective September 23, 2010; 42 SDR 51, effective October 13, 2015.

67:16:46:08. Provider must maintain and make available certain documentation. As required by the American Diabetes Association and the Department of Health, the provider must prepare an initial assessment of the individual's needs, develop an education plan based on the assessmen…

Rule 67:16:46:09 Application of other chapters. 67:16:46:09. 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: 28 SDR 84,…

67:16:46:10. Utilization review. The department may provide utilization review of diabetes self-management training covered under this chapter through computerized claims processing and postpayment review. Source: 28 SDR 84, effective December 20, 2001; 49 SDR 21, effective Septe…

Rule 67:16:47:01 Definitions. 67:16:47:01. Definitions. Terms used in this chapter mean: (1) "Certification team," a team of medical professionals that determines whether an individual is in need of psychiatric services; (2) "Department," the Department of Social Services; (3) "J…

Rule 67:16:47:02 Facilities eligible for reimbursement -- In-state. 67:16:47:02. Facilities eligible for reimbursement -- In-state. The following types of psychiatric residential treatment facilities are eligible to receive reimbursement for services provided to individuals under…

Rule 67:16:47:03 Facilities eligible for reimbursement -- Out-of-state. 67:16:47:03. Facilities eligible for reimbursement -- Out-of-state. An out-of-state facility is eligible for reimbursement if the following requirements are met: (1) The facility has a residential treatment p…

Rule 67:16:47:04 Treatment as a covered service -- Conditions that must be met. 67:16:47:04. Treatment as a covered service -- Conditions that must be met. Treatment at an eligible facility is a covered service if the following conditions are met: (1) The individual is under the …

Rule 67:16:47:04.01 State review team. 67:16:47:04.01. State review team. The state review team shall consist of at least one representative from each of the following state agencies: (1) The Department of Corrections; (2) The Department of Social Services; and (3) The Department…

Rule 67:16:47:04.02 State review team -- Responsibilities. 67:16:47:04.02. State review team -- Responsibilities. In order to meet the covered service conditions of subdivision 67:16:47:04(2), the state review team must determine that the following conditions exist: (1) Outpatien…

Rule 67:16:47:04.03 Certification team. 67:16:47:04.03. Certification team. The department shall establish a certification team to determine whether an individual is in need of psychiatric services. The team must include at least one physician and must be knowledgeable about the …

Rule 67:16:47:04.04 Certification team -- Responsibilities. 67:16:47:04.04. Certification team -- Responsibilities. In order to meet the covered service conditions of subdivision 67:16:47:04(3), the certification team, based on medical documentation, must certify the existence of…

Rule 67:16:47:04.05 Diagnoses recognized for treatment. 67:16:47:04.05. Diagnoses recognized for treatment. The diagnoses recognized for treatment under the provisions of this chapter are limited to the following: (1) Schizophrenia; (2) Psychotic disorders; (3) Depressive disorde…

Rule 67:16:47:04.06 Problems associated with diagnosis. 67:16:47:04.06. Problems associated with diagnosis. In order to meet the conditions of subdivision 67:16:47:04.04(5), an individual who has a diagnosis listed in § 67:16:47:04.05 must also be experiencing problems related to…