The NEMT program may reimburse you for mileage, lodging and meals at the current rate of payment.

A recipient may not receive reimbursement for lodging and meals for days the recipient is an inpatient in a hospital or medical facility.

In order for you to be reimbursed for your travel you must be on a medical assistance program that provides Medicaid travel coverage.

Travel must be to the closest medical facility or medical provider capable of providing the necessary services. The service must be a Medicaid covered service that is provided by a medical provider who is enrolled in SD Medicaid.

No. Mileage is limited to the actual miles between two cities and does not include miles driven within the city.

Travel to the closest PCP or HHP is reimbursable. If travel is not to the closest PCP or HHP, travel will only be reimbursed if a "good cause" exception has been approved by Medical Services. Lodging and meals are not reimbursable when travel is to a PCP or HHP.

Yes. Trips to medical specialty providers other than your PCP or HHP require a referral.

There are two options to request travel reimbursement:

1. The new online NEMT Portal will allow you to:

   • Update and maintain your personal and banking information.
   • Submit claims online.
   • Track the status of your claim.
   • Receive and review correspondence and Paid Claims Statements.

   Before you begin using the online portal, select the appropriate instructional video below that will help you navigate the NEMT Portal.

2. A NEMT Form must be completed and submitted for each medical trip.  This form, along with any necessary documentation, may be turned in at your local office or mailed directly to:
   
   Department of Social Services
   Office of Finance/EBT
   700 Governors Drive
   Pierre, SD 57501
   Fax: 605.773.8461
   Email: DSS.EBTSTATEOFFICE@state.sd.us.

The Medicaid NEMT Form must be completed and signed by the recipient, parent or guardian.  The Medical Provider section of the form must be completed and signed by the receptionist, nurse or medical provider.

A recipient will received reimbursement when all requested forms and verifications have been received in our office and processed.

The NEMT program must receive a completed claim form within six months following the month the service was provided.

A new form only needs to be completed when you are notifying NEMT of a change to how you want to receive your reimbursement, or a name change and /or address change.

Yes. A motel receipt is required for lodging reimbursement. Lodging is reimbursable when the provider is at least 150 miles from the recipient's city of residence and travel is to obtain specialty care or treatment that result in an overnight stay.

You will receive your reimbursement when all required forms and verifications have been received in our office and processed. Claims are processed in the order they are received in our office. You will receive a Paid Claims Statement showing specific travel dates and amounts in the mail once your claim has been paid.

You can obtain the Medicaid Non-Emergency Medical Travel Form at your local Department of Social Services Office, on the DSS online Forms and Publications page or by calling 866.403.1433.

Mail or fax the reimbursement form to the medical provider to complete the Medical Provider section. The medical provider can fax the completed form to our office.

No. Meals will be reimbursed only if an overnight stay is medically necessary and the overnight meets the lodging requirement criteria.

Medicaid covered services received more than 50 miles outside of the state of South Dakota, except Bismarck, ND, will require prior authorization. This applies to all Medicaid recipients, including those not in the PCP or HHP program.

If your doctor recommends you see a doctor out-of-state, please ask your doctor if prior authorization is needed before you make the appointment. If approval is not given, you will be responsible for the medical bill and travel costs.

Prior authorization must be approved before travel expenses can be approved or paid.

NOTE: If you are in the PCP or HHP program and traveling to Bismarck, ND, a referral from your PCP or HHP is still required. If you are not in the PCP or HHP program, travel will only be reimbursed if Bismarck, ND, is the closest provider capable of providing the services.

No. NEMT will only reimburse for the recipient and one parent/guardian/escort at the least costly method to the State.

No. NEMT can only reimburse for nights the recipient and/or escort are present in the lodging establishment.

All services requiring a prior authorization and the associated Prior Authorization Request forms can be found on our Prior Authorization page along with the Prior Authorization Manual. 

Out-of- state providers who are not enrolled as a South Dakota Medicaid provider must follow the process to obtain prior authorization beginning with the submission of a Prior Authorization Request Form. If the request is approved, the provider will receive written notification stating the determination was made pending enrollment.  Once the approved service(s) have been provided, the provider must complete the online enrollment application with South Dakota and submit the resulting claim and the written prior authorization approval notification with the Provider Enrollment documentation.
Please note that Administrative Rule of South Dakota §67:16:35:04 requires claims to be filed within 6 months of the date of service.

South Dakota Medicaid does not have a paper application.  Applications can be started online. If there are extenuating circumstances regarding online submission, please contact DSS at 605.773.3495

Applications and modifications are generally processed in the order in which they are submitted and response time can vary depending on the volume of other applications and modifications and the time of submission.

If a provider’s NPI is required to be included as a servicing or rendering provider on a CMS 1500 claim form or equivalent 837P claim loop/segment as captured in the billing manuals, the provider must be enrolled.

NPIs belonging to individuals that are listed only as attending, referring, or operating providers that are not billed by an IHS facility generally do not have the complete an enrollment application.  South Dakota will use its streamlined enrollment process during the claim adjudication process to ensure the listed attending, referring, or operating individual is meets the requirements to be deemed enrolled for claim processing.  These requirements include items such as being a type of provider eligible to enroll, active license in good standing for location of rendered services, not deceased on date of service.

Enrolled providers who have not had paid claims within a 24 month period may be terminated for inactivity. Providers are required to maintain their record as changes occur and also complete revalidation in accordance to federal requirements upon South Dakota Medicaid notice. The revalidation process is anticipated to occur every 3-5 years.

Providers may access their remittance advices via the Provider Online Portal.  The Provider Online Portal gives the provider the ability to view and download copies of Remittance Advices. 

• Provider Online Portal Login
• Information about how to access the portal
• For assistance and questions regarding the Portal providers may send an email to DSSonlineportal@state.sd.us or call 605.773.3495.

South Dakota Medicaid excluded providers can be found on the U.S. Department of Health & Human Services Office of Inspector General’s Exclusions Database.

South Dakota’s health home program offers enhanced health care services to Medicaid recipients with chronic conditions like asthma, COPD, diabetes, heart disease, hypertension, obesity, substance use disorder, mental health conditions, pre-diabetes, tobacco use, cancer, hypercholesterolemia, depression, and musculoskeletal and neck/back disorders.

The full definition of core services can be found by clicking here.

Health Homes are encouraged to utilize health information technology to more efficiently and effectively coordinate the care of Health Home patients.

Through the provision of the six core services, the Health Home initiative aims to reduce inpatient hospitalization and emergency room visits, increase the integration between physical and behavioral health services and enhance transitional care between institutions and the community.

South Dakota implemented Health Homes to improve health outcomes and experience of care for eligible Medicaid recipients, while also realizing cost savings from better coordinated care for that population. See how this program has gained efficiencies and improved health outcomes by viewing our data dashboard.

South Dakota has two types of Health Homes -- those led by Primary Care Providers and those led by a Community Mental Health Centers -- to serve Medicaid recipients with complex health care needs resulting in high costs to Medicaid. Individuals who are eligible for these two health homes include:

1. Medicaid recipients with two or more chronic conditions or recipients with one chronic condition who are at risk for a second chronic condition.
   
   A. Chronic conditions include: Mental Health Condition, Substance Use Disorder Asthma, COPD, Diabetes, Heart Disease, Hypertension, Obesity, Musculoskeletal and Neck/Back disorders.
   
   B. At-risk conditions include: Pre-Diabetes, tobacco use, Cancer, Hypercholesterolemia, Depression, and use of multiple medications (6 or more classes of drugs).
   
   
2. Recipients who have a Severe Mental Illness or Emotional Disturbance

Providers who would like to serve as a designated provider and feel they meet the required provider standards should complete an application.

Click here to view the Health Home application training. Questions on the application can be directed to the number on the webpage. The Department of Social Services will review completed applications to ensure each provider meets the standards. After the application is approved, onsite training will be provided to each Health Home.

Each Health Home is led by one or more designated providers. Each designated provider leads an individualized team of health care professionals and support staff to meet the needs of each recipient. A designated provider team may include a health coach/care coordinator/care manager, chiropractor, pharmacist, support staff and other services as appropriate and available.

Designated providers for Health Homes include providers licensed by the State of South Dakota who practice as a primary care physician, (e.g., family practice, internal medicine, pediatrician or OB/GYN), physician’s assistant, advanced practice nurse practitioner, Federally Qualified Health center, Rural Health Clinic, Indian Health Service, clinic group practice; or a mental health professional working in a Community Mental Health Center.

Health Homes are located where there are qualified designated providers are willing to serve the needs of those eligible. You may choose your HH online with our Online Provider Selection Tool.

Medical Services are funded exactly as they are now. The Health Home provider will be paid a per-member per-month (PMPM) payment based on the tier of the recipients to cover the cost of providing the 6 core services required by Health Homes.