South Dakota Administrative Code

Rule 67:16:47:05 Prior approval required for admission. 67:16:47:05. Prior approval required for admission. Before an individual may be admitted to a facility for treatment, the certification team must approve the individual’s admission to the facility. Approval is based on a rev…

Rule 67:16:47:06 Prior approval required for admission to intensive residential or psychiatric residential treatment facilities. 67:16:47:06. Prior approval required for admission to intensive residential or psychiatric residential treatment facilities. Repealed. Source: 32 SDR 3…

Rule 67:16:47:07 Provider responsibility -- Required notice to child’s placing agency. 67:16:47:07. Provider responsibility -- Required notice to child’s placing agency. Before the provider admits an individual to a facility and each month thereafter that the individual remains i…

Rule 67:16:47:08 Requirements for continued stay. 67:16:47:08. Requirements for continued stay. An individual’s continuous and uninterrupted stay in a facility is a covered service if the certification team determines, based on the child’s progress report required by § 67:42:08:0…

Rule 67:16:47:09 Covered services. 67:16:47:09. Covered services. Services covered under the provisions of this chapter are limited to those authorized by the certification team. Source: 32 SDR 33, effective August 31, 2005; 34 SDR 180, effective December 26, 2007. General Author…

Rule 67:16:47:09.01 Nonreimbursable days. 67:16:47:09.01. Nonreimbursable days. The following are not reimbursable under the provisions of this chapter: (1) The day of discharge; (2) Days the individual is in a juvenile detention center; and (3) Days when the individual is absent…

Rule 67:16:47:10 Termination of coverage. 67:16:47:10. Termination of coverage. An individual’s care becomes a noncovered service when the certification team determines that one of the following has occurred: (1) The individual has reached maximum potential in the current setting…

Rule 67:16:47:11 Rate of payment. 67:16:47:11. Rate of payment. The department shall establish a provider's rate of payment. The payment shall be provider specific and contained in the provider’s contract with the department. The department shall base the rate on historical cost …

Rule 67:16:47:12 Claim requirements. 67:16:47:12. 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 individual’s full name and identification number as they …

Rule 67:16:47:13 Application of other chapters. 67:16:47:13. 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: 32 SDR 33,…

Rule 67:16:47:14 Utilization review. 67:16:47:14. Utilization review. The department may conduct utilization reviews on the following three levels: (1) Computerized claims processing; (2) Post payment review; and (3) Peer review. Source: 32 SDR 33, effective August 31, 2005. Gene…

67:16:48:01. Definitions. As used in this chapter: (1) "Addiction counselor" means an individual who has met the standards established by the Board of Addiction and Prevention Professionals and is recognized as a Licensed Addiction Counselor or Certified Addiction Counselor, by t…

Rule 67:16:48:02 Covered services. 67:16:48:02. Covered services. Substance use disorder treatment services covered under this chapter are limited to the following: (1) The integrated assessment; (2) Crisis intervention services; (3) Early intervention services; (4) Outpatient tr…

Rule 67:16:48:03 Services not covered. 67:16:48:03. Services not covered. The following services are not covered under the provisions of this chapter: (1) Treatment for a diagnosis of substance use disorder that exceeds the limits established by the division, unless prior authori…

Rule 67:16:48:04 Services requiring prior authorization. 67:16:48:04. Services requiring prior authorization. The following services require prior authorization: (1) Medically-monitored intensive inpatient programs; (2) Clinically-managed low intensity residential treatment progr…

Rule 67:16:48:05 Prior authorization requirements. 67:16:48:05. Prior authorization requirements. The requirements for prior authorization of a medically monitored intensive inpatient program, clinically-managed low-intensity residential treatment program for pregnant women or wo…

Rule 67:16:48:06 Prior authorization for psychiatric residential treatment programs for substance use disorders. 67:16:48:06. Prior authorization for psychiatric residential treatment programs for substance use disorders. The requirements for prior authorization of a psychiatric …

Rule 67:16:48:07 Repealed. 67:16:48:07. Short-term relapse treatment for an adolescent with a substance use disorder. Repealed. Source: 43 SDR 80, effective December 5, 2016; 44 SDR 94, effective December 4, 2017; 44 SDR 192, effective July 2, 2018.

Rule 67:16:48:08 Treatment for a substance use disorder -- Out-of-state. 67:16:48:08. Treatment for a substance use disorder -- Out-of-state. Out-of-state treatment for a substance use disorder is limited to those services provided in a facility which is licensed or accredited in…

Rule 67:16:48:09 Repealed. 67:16:48:09. Treatment for a pregnant woman with a substance use disorder -- In-state. Repealed. Source: 43 SDR 80, effective December 5, 2016; 44 SDR 94, effective December 4, 2017; 44 SDR 192, effective July 2, 2018.

Rule 67:16:48:10 Repealed. 67:16:48:10. Treatment for a pregnant woman with a substance use disorder -- Out-of-state. Repealed. Source: 43 SDR 80, effective December 5, 2016; 44 SDR 94, effective December 4, 2017; 44 SDR 192, effective July 2, 2018.

Rule 67:16:48:11 Prior authorization required for care beyond established service limit. 67:16:48:11. Prior authorization required for care beyond established service limit. Prior authorization by the division is required for a continued stay beyond the length-of-stay service lim…

Rule 67:16:48:12 Rate of payment -- Treatment for a substance use disorder. 67:16:48:12. Rate of payment -- Treatment for a substance use disorder. A service covered under this chapter is subject to the limits listed on the department's billing guidance website. Payment for the t…

Rule 67:16:48:13 Claim requirements -- Substance use disorders. 67:16:48:13. Claim requirements -- Substance use disorders. A claim for a substance use disorder treatment service provided under this chapter shall be submitted to the department on a form or in an electronic format…

Rule 67:16:48:14 Recognizing a tribal program as a participating provider. 67:16:48:14. Recognizing a tribal program as a participating provider. A tribal substance use disorder treatment program seeking to participate as a provider under the provisions of this chapter shall subm…

Rule 67:16:48:15 Application of other chapters. 67:16:48:15. Application of other chapters. In addition to the rules contained in this chapter, providers and recipients shall meet the requirements of chapters 67:16:01, 67:16:26, 67:16:33, 67:16:34, and 67:16:35. Source: 43 SDR 80…

Rule 67:16:49:01 Definitions. 67:16:49:01. Definitions. Terms used in this chapter mean: (1) "Charitable organization," a provider that has an agreement with the department to advance expenses for non-emergency medical travel services on behalf of Medicaid recipients. A charitabl…

Rule 67:16:49:02 Travel requirements. 67:16:49:02. Travel requirements. Travel services must meet the following requirements: (1) Travel is from an eligible recipient's city of residence to a medical provider located in another city, between medical providers located in different…

Rule 67:16:49:03 Covered services. 67:16:49:03. Covered services. Travel services are limited to the following items, which must meet the requirements of § 67:16:49:02: (1) Mileage if the transportation is outside the recipient's city of residence and provided when all other mean…

Rule 67:16:49:04 Services not covered. 67:16:49:04. Services not covered. In addition to services not specifically listed as covered in § 67:16:49:03 the following services are not covered: (1) Travel to services that do not meet the requirements of Article 67:16; (2) Out-of-stat…

Rule 67:16:49:05 Rate of payment. 67:16:49:05. Rate of payment. The rate of payment for travel covered under § 67:16:49:03 is available on the department's fee schedule website and limited to the following: (1) Mileage outside the recipient's city of residence, which is limited t…

Rule 67:16:49:06 Claim requirements. 67:16:49:06. Claim requirements. A claim for travel services provided under this chapter shall be submitted on a form available from the department. The form shall contain the following information: (1) The recipient's full name; (2) The recip…

Rule 67:16:49:07 Utilization review. 67:16:49:07. Utilization review. Utilization review for travel services may be conducted on the following levels: (1) Computerized claims processing; (2) Postpayment review; and (3) Peer review. Source: 44 SDR 94, effective December 4, 2017. G…

Rule 67:16:49:08 Recovery of amounts overpaid. 67:16:49:08. Recovery of amounts overpaid. The department considers a payment made on behalf of a recipient for non-emergency medical travel assistance that exceeds the amount reimbursable under this chapter to be an overpayment and …

Rule 67:16:49:09 Application of other chapters. 67:16:49:09. 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, 67:16:33, 67:16:34, and 67:16:35. Source: 44 SDR 94, effective…

67:16:50:01. Definitions. Terms used in this chapter mean: (1) "Active treatment," the implementation of a program of specialized and generic training, treatment, health services, and related services, which leads to the acquisition of the behaviors necessary for an individual to…

67:16:50:02. Preadmission screening and resident review. A medicaid-certified nursing facility shall, upon an individual's admission or if a resident's condition has a significant change: (1) Evaluate a resident or applicant for a serious mental illness and an intellectual or dev…

67:16:50:03. Level I screen. A referring or accepting provider shall conduct a Level I screen to determine if an individual seeking medicaid-certified nursing facility services has a serious mental illness or an intellectual or developmental disability. Source: 52 SDR 41, effecti…

67:16:50:04. Circumstances that do not require a Level II evaluation. Following the Level I screen, an individual is exempt from a Level II evaluation if: (1) There is no substantiated diagnosis of a serious mental illness or an intellectual or developmental disability; (2) The i…

67:16:50:05. Exempt hospital discharge. An individual is exempt from the preadmission screening and resident review process following a hospital discharge if: (1) The individual is admitted to a medicaid-certified nursing facility, directly from a hospital, after receiving acute …

67:16:50:06. Categorical determinations for Level I. The State Mental Health Authority or State Intellectual Disability Authority shall make an advance group categorical determination for a nursing facility applicant or resident who may have a preadmission screening and resident …

67:16:50:07. Level II review. The State Mental Health Authority or State Intellectual Disability Authority shall conduct a Level II review to determine whether a medicaid-certified nursing facility, specialized services, or both, is appropriate for an individual. The individual m…

67:16:50:08. Level II State Mental Health Authority evaluation. An independent evaluator shall complete the Level II evaluation based on an independent physical and mental evaluation performed by a person or entity other than the State Mental Health Authority for an individual wi…

67:16:50:09. Level II State Mental Health Authority determination. The independent evaluator, as described in 42 C.F.R. § 483.106 (April 28, 1993), shall submit an evaluation report and all data collected to the authority for final determination. The authority shall determine if …

67:16:50:10. Level II State Intellectual Disability Authority evaluation. The State Intellectual Disability Authority shall complete the Level II evaluation for an individual with an identified intellectual or developmental disability. A preadmission screening and resident review…

67:16:50:11. Level II State Intellectual Disability Authority determination. The State Intellectual Disability Authority shall complete a Level II evaluation using all evaluated data and completed assessments to determine if an individual requires the level of services provided b…

67:16:50:12. Determination of specialized services. If the State Mental Health Authority or State Intellectual Disability Authority determines that an individual requires medicaid-certified nursing facility services, the authorities must also determine whether the individual woul…

67:16:50:13. Notification of Level II determination. The State Mental Health Authority, State Intellectual Disability Authority, or both when applicable, shall issue a written notification of the Level II review determination. The notification must include: (1) Whether a Medicaid…

67:16:50:14. Termination of a preadmission screening and resident review. The preadmission screening and resident review process may be terminated by the State Mental Health Authority or State Intellectual Disability Authority at any time during the evaluation or determination if…

67:16:50:15. Timeliness of a Level II determination. The State Mental Health Authority and State Intellectual Disability Authority shall make each Level II determination within an annual average of seven to nine business days of receipt of the Level I referral. Source: 52 SDR 41,…