What is South Dakota Medicaid?
Medicaid is a state and federally funded program providing medical coverage for individuals who meet certain eligibility guidelines. If you are eligible, Medicaid acts as your insurance company and pays for the cost of medically necessary services such as visits to the doctor, hospital, dentist, specialist, etc. These services
are subject to cost-sharing by the enrolled individuals and are authorized and limited by South Dakota Administrative Rule.
Am I eligible for Medicaid?
Qualification for Medicaid depends on your income and circumstances. For more information, visit your local office.
How do I know what services are covered by Medicaid?
Contact your medical provider or South Dakota Medicaid at 1.800.597.1603. You can also send an email to Medical@state.sd.us
How do I choose a Medicaid provider?
Before seeing a provider, you should confirm the provider is a South Dakota Medicaid provider. When making the first contact with the provider by phone, ask if they accept South Dakota Medicaid. If they do, you can schedule an appointment. If they are not currently enrolled you can ask them if they would consider enrolling.
Do I need a Primary Care Provider (PCP)? If so, how do I select one?
If you are required to participate in the Managed Care Program, the Department of Social Services will notify you in writing that you need to choose a Primary Care Provider (PCP). A PCP is a physician or clinic who you see for most of your medical care.
DSS will give you a selection form and a list of PCPs in your area. You need to complete the form by choosing a PCP for each eligible member of your family. View a list of PCPs.
If you are required to participate in Managed Care and you do not choose a PCP, DSS will choose one for you. Contact us at 1.800.597.1603 if you have questions. Save time by selecting your PCP online.
Can I change my Primary Care Provider?
You can change your PCP in several different ways:
Can I see a provider other than my PCP?
If you are in Managed Care, a referral is required from your PCP or designated covering provider prior to receiving services from another provider, even if it is a specialist or a hospital service (including any non-emergent ER service), acute/urgent care visits or other designated services. View the recipient handbook for more services that would require a referral.
A referral can be made by your PCP via telephone referral, physician order, prescription, referral card, or certificate of medical necessity.
Is a paper Referral Card required for Managed Care recipients?
No. A proper referral can be provided in many ways, i.e. a telephone referral, a physician order, a prescription, a certificate of medical necessity, etc. As long as the referral mechanism used provides the "referred to" medical provider with the Managed Care necessary information to process the claim as indicated on a referral card (PCP name and #, length of referral, type of service to be provided, date, recipient name).
The referral card is simply a tool indicating the required information needed by the "referred to" provider.
I forgot the name of my child's primary care physician. What do I need to do now?
Contact your Benefits Specialist at your local DSS office
or call 1.800.597.1603 with your child's Medicaid ID number.
Can I go to the Emergency Room?
When you have a serious health problem that could cause lasting injury or death, you can receive care at the emergency room (ER) and Medicaid will assist with payment.
If a medical problem arises that may not be an emergency and you are not sure what to do, call your PCP or on-call provider if it is after hours. If the PCP or on-call provider contacts the ER and refers you prior to a non-emergent service, Medicaid will assist with the payment of these services.
If you go to the ER for a non-referred, non-emergent service, you will be responsible for payment of these services.
I took my child to the ER due to my primary care physician (PCP) being closed; it was midnight on a Saturday. I am now being billed by the hospital for not providing a referral. I thought ER visits were covered by Medicaid?
If you did not obtain prior referral from your PCP and the visit is not determined to be an emergency by ER staff, then you may be billed for the services. Only emergent visits to the ER are covered by South Dakota Medicaid without a PCP referral.
I've been told I have Medicaid, why am I still getting a bill?
There are many reasons you may be receiving a bill. Some common issues include:
- You were not eligible for Medicaid on the date you received care.
- The provider is not enrolled with South Dakota Medicaid.
- You did not get a referral card from your PCP if you are in the Managed Care Program or Health Homes Program.
- You did not get the service prior-authorized if it was required to do so.
Does South Dakota Medicaid cover dental services?
South Dakota Medicaid includes many dental services for adults and children. If you are 21 or older, dental services that are not emergency services are limited to a total of $1,000 for the Fiscal Year, July 1 to June 30.
South Dakota Medicaid Medical Services does NOT cover orthodontics for adults. Orthodontic treatment is a benefit only for children in limited, medically-necessary circumstances
How can I find a Medicaid dental provider?
Visit Insure Kids Now
and click on the Medicaid link under South Dakota.
You can also call the Delta Dental Medicaid Referral Line at 1.800.627.3961.
Why am I receiving medical claims for my hospital stay when I am on South Dakota Medicaid?
It is possible that your provider does not know you are eligible for Medicaid. Please be sure to provide your provider with your Medicaid ID card each time you receive a service. If you contact your provider and they inform you that your Medicaid eligibility has ended, please contact your local DSS office
to inquire about possible eligibility.
I am being told my child has another type of medical insurance other than Medicaid. My child DOES NOT have any other insurance. What do I do?
Contact your Benefits Specialist at your local DSS office
and provide him/her with the correct information. It will then be corrected in to our system and you will be issued a new card. If you did not apply at a local office, please call 1.877.999.5612.
We were visiting family in another state and had to fill a prescription for our child through a non-South Dakota Medicaid provider. How do I get reimbursed for the prescription?
South Dakota Medicaid cannot directly reimburse recipients.
The pharmacy where you purchased the prescription will need to enroll with South Dakota Medicaid and submit the claim to South Dakota Medicaid for payment. Call 1-800-597-1603 so South Dakota Medicaid can work with the facility to get them enrolled.
My child broke his glasses for the second time in the past 15 months. The eye doctor is telling me South Dakota Medicaid will not cover another pair. How is my child supposed to see without glasses?
South Dakota Medicaid will replace eyeglasses that are broken beyond repair and are returned to the provider.
What do I do if my child's Medical Benefit's card has an incorrect spelling or date on it?
Contact your Benefits Specialist at your local DSS office
and provide him/her with the correct information. It will then be corrected in our system and you will be issued a new card. If you did not apply at a local office, please call 1.877.999.5612.
I was in a car accident in another state and had to be airlifted to a hospital. I am now receiving a bill. Why is this claim being denied?
The provider may not be a South Dakota Medicaid provider. In this case, the provider will need to enroll with South Dakota Medicaid as a provider so they can submit the claim for payment. Call 1.800.597.1603 so South Dakota Medicaid can work with the facility to get them enrolled.
I just took my disabled child, who is on Supplement Security Income (SSI), to the doctor and was told he/she is not eligible for Medicaid. Why is this happening?
In South Dakota individuals who receive a Supplement Security Income (SSI) payment are automatically eligible for Medicaid. If your child is no longer receiving a SSI payment his/her eligibility would end. The Social Security Administration determines the eligibility for payments.
When this happens you will receive a notice from DSS instructing you to contact the local office nearest you to explore other possible eligibility options.
If the payment ended, but you have since received another awards letter stating you are eligible for payment, it is possible DSS has not yet been notified. If you believe this is the case please call 1.877.999.5612.
How do I obtain a certificate of coverage for my new insurance?
Please call 1.877.999.5612 and ask for a certificate of coverage.
Does South Dakota Medicaid cover the lap band procedure?
Requests for the lap band surgery can be submitted for prior authorization
consideration. Documentation must include conservative weight loss efforts, co-morbidities, psychiatric evaluation, along with a surgical evaluation.
Does South Dakota Medicaid pay for contact lenses?
Coverage depends on the type and reason
contacts were prescribed. Please speak with your provider to learn more about coverage options.
Will my child's sports physical be covered by South Dakota Medicaid
Children ages 3 through 20 are entitled to one comprehensive well child exam each year. Sports physicals, completed through this exam, are covered. Please remember that one full year (12 full months) must pass between each well child exam. If it has not been a full year since the last well child exam, you may be responsible for the bill.
How do I add my newborn child to my caseload?
Please contact your Benefit Specialist at your local DSS office
or call 1.877.999.5612.
What do I do if I lose my Medical Benefit ID card?
Please contact your Benefits Specialist at your local DSS office
or call 1.877.999.5612.
Will my child be covered this summer when he/she goes to stay with his/her mother/father?
Your child will remain eligible for Medicaid provided all other eligibility factors remain the same. However, it is important to remember that if your child needs medical services out of state, he/she will need to go to a provider who accepts South Dakota Medicaid. Any out-of-state services will need to receive prior authorization before they will be covered by South Dakota Medicaid.
In addition, if your child is in the Managed Care Program, he/she will need to get a referral from his/her primary care physician.
What do I do if my prescription is NOT covered?
Why is an Out-of-State Prior Authorization requirement being implemented?
In order to improve health outcomes and efficiently utilize South Dakota Medicaid and CHIP resources, care should be provided in, or as close to South Dakota as possible. Prior authorization of out-of-state services helps ensure all alternatives are considered and that seeking treatment out-of-state care is medically necessary.
Are all services provided by an out-of-state provider subject to this requirement?
No. We have exempted some services from this requirement. Services that do not require prior authorization to be provided out-of-state include certain lab, radiology or pathology services, durable medical equipment, and pharmacy. These have been exempted as they are expected to be an integral part of another provider visit or procedure that will require prior authorization. Additionally, these services are often performed by out-of-state providers while the Medicaid recipient is physically in South Dakota.
What process should providers follow for emergency inpatient admissions or urgent situations during holidays or weekends?
If the inpatient hospitalization is the result of an emergency, the prior authorization can be granted retroactively.
In the case of inpatient hospitalizations, hospitals must submit the Prior Authorization Request Form to South Dakota Medicaid within 48 hours and an expedited determination on these cases will be made within two business days. Providers should also expect to provide at least weekly updates on hospitalizations to South Dakota Medicaid after notification.
What process do we follow for non-emergency situations?
A Prior Authorization Request Form
must be submitted before a recipient receives non-emergency service out-of-state. The documentation must provide details of the anticipated service. The Prior Authorization Request Form should be submitted as soon as possible after service has been prescribed or a referral has been made to allow South Dakota Medicaid time to explore medical necessity and verify the service(s) cannot be provided in South Dakota.
What if a patient already has a service scheduled?
Submit the Prior Authorization Request Form
and supporting medical records as soon as possible to allow South Dakota Medicaid time to review the situation and issue a determination prior to the scheduled service.
How long will it take to obtain a prior authorization?
A prior authorization determination may take up to 30 days for an elective service. These will be completed in the order they are received. If the inpatient hospitalization admission is the result of an emergent or urgent situation, or is a transfer situation, the Prior Authorization Request Form
should be submitted within 48 hours and authorizations will be expedited and completed within 2 business days of the request.
Who is responsible for obtaining the out-of-state prior authorization?
The referring provider is expected to initiate the out-of-state prior authorization request and provide supporting documentation. This responsibility should not be delegated to the recipient. When referring a Medicaid recipient to services out-of-state, the prior authorization request form should be submitted upon referral and must include an explanation of the need for care out-of-state when an in-state option is available.
What if the recipient has Medicare?
If the patient has Medicare in addition to South Dakota Medicaid, please follow the Medicare requirements, as South Dakota Medicaid’s payments are contingent upon Medicare’s determination.
What if the recipient has other private health insurance (PHI)?
If the patient has other private health insurance, please follow the requirements of the primary insurance in addition to seeking South Dakota Medicaid approval as the secondary payer.
Prior authorization from South Dakota Medicaid is required for the recipient to receive assistance with transportation, food, and lodging reimbursement even if there is no need for South Dakota Medicaid to reimburse the medical service.
What do providers need to do to obtain prior authorization?
A Prior Authorization Request Form
must be submitted along with additional information about the out-of-state prior authorization requirement. The form can be submitted by the provider where services will be provided or by the recipient’s primary or specialty care provider in advance of an anticipated out-of-state service.
The Prior Authorization Request Form must be complete and must be accompanied by supporting medical documentation. The referring provider must also verify that there is no provider in South Dakota, or closer to South Dakota, who can provide the service. A written notification of approval or denial will be sent to the contact provided as soon as a determination is made.
What if I am not an enrolled South Dakota Medicaid provider?
Out-of- state providers who are not enrolled as a South Dakota Medicaid provider must obtain prior authorization and provide the approved service(s) prior to enrolling in South Dakota Medicaid. These providers should submit the Prior Authorization Request Form. If the request is approved, the provider will receive written notification stating the determination was made pending enrollment. The provider must 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.
How are prior authorization determinations made?
Registered nurses review each request for medical necessity criteria. All covered services must be medically necessary per Administrative Rule of South Dakota §67:16:01:06.02
To ensure that the out-of-state service is the most conservative option to meet the recipient’s needs, the registered nurse will also verify that the service is going to be provided at the closest possible location.
Registered nurse reviewers may also consult the South Dakota Medicaid Medical Director to assist in complex determinations.
Does this requirement apply to children in DSS custody?
No, children in DSS custody are exempt from this requirement.
Does this requirement apply to services that already require a prior authorization?
No, services that require prior authorization regardless of the location do not also need to be prior authorized for out-of-state. Only one prior authorization is necessary for a given service.
What form should providers use?
Services requiring prior authorization are listed on the prior authorization website
. Providers should use the form associated with the type of service they are seeking prior authorization for. If the service only requires prior authorization because it is being done out-of-state, the Out-of-State Prior Authorization Request form should be utilized.
How are physician services covered during an inpatient hospital stay?
Only one prior authorization is needed for the hospital stay. Physician services are included as part of the prior authorization for the inpatient stay. A prior authorization will be issued to the prior authorization contact for the inpatient facility for the dates of the approved hospital stay. In addition to the hospital facility, this authorization must be shared with all physicians to use for visits billed during that hospital stay.
Which hospitals are required to submit day six notification forms?
All in‐state hospitals, hospitals within 50 miles of the South Dakota border, and hospitals in Bismarck, ND must submit the form for Medicaid recipients on day six of an acute inpatient hospital admission.
Is the notification form required for inpatient cases where South Dakota Medicaid is the secondary or tertiary payer?
Is notification required for all Medicaid programs regardless of the type of Medicaid assistance that recipient is receiving, i.e. QMB, Home Care Waiver, SSI Medicaid, Long Term Care, Assisted Living Waiver, CHIP?
Yes, but this notification process applies only to acute inpatient hospital stays.
Is the notification form required for inpatient hospital stays involving patients with pending South Dakota Medicaid applications (including inmates)?
No. The form must be submitted at the point Medicaid eligibility is approved if the stay is at day six or beyond.
Do we need to report inpatient hospitalizations if Medicaid eligibility determination is made retro‐actively?
Only if the recipient is still an inpatient when the eligibility is approved and the stay is at day six or beyond. Notice does not need to be provided for retro‐active stays if the patient has already been discharged.
Why are hospitals being required to submit notification for extended acute inpatient stays?
This requirement is consistent with other insurers and is intended to assist DSS in identifying opportunities to improve efficiency within South Dakota Medicaid.
How will this length of stay information be used? When will hospitals receive calls from a DSS nurse?
This information will be utilized to increase efficiencies in South Dakota Medicaid. DSS nurses focus on projected stays of extended hospitalizations, situations that are not consistent with standard length of stay per diagnosis, and providing assistance to hospitals to develop strategies for timely and appropriate care transitions.
Where is the form located? How do I submit the form?
The inpatient reporting form is located on our website
; click on the fill out the form link. The form must be submitted directly online.
If I submit the form online will that form be available to submit the discharge date or will I have to resubmit a new form?
Yes. When you login, click on the option to Add discharge information. Then click on the dropdown box beside Confirmation No. to find the original admission form to update it.
Does the day of admission count towards the six days for reporting purposes?
No. For example, if a recipient is admitted on the first of the month, the notification form should be submitted on the seventh.
If the notification form is submitted online on day seven or later, will the inpatient hospital claim be denied? Will appeals be considered?
The form must be submitted during day 6 of the admission. At this time, the notification process is not tied to claim adjudication as we anticipate that South Dakota Medicaid providers will comply with this process.
Will I receive a confirmation number after I electronically submit the form so I know it was received?
Yes, you will receive a confirmation number for tracking purposes. The confirmation number will allow you to add discharge information.
When is the discharge form required to be submitted?
The discharge notification form is required at the time of discharge unless it is after 5 pm, in which case the form may be submitted the following business day by noon.
Will the program be staffed on weekends and holidays? Is this something that can wait until Monday or after the holiday for both the initial reporting and the discharge forms?
Both the initial notification and the discharge forms may be submitted by noon the following business day.
Do observations days (OBV) count toward the six inpatient days?
If the inpatient stay is for a DRG‐exempt unit (Neo‐natal intensive care unit, rehabilitation, and psychiatric) unit, do I have to report the stay?
No, DSS has already been notified and will complete this form for the provider.
What is a Health Home?
The Health Home is a federally defined initiative in the Affordable Care Act (ACA). The initiative is designed for Medicaid recipients with multiple chronic conditions.
Health Homes are part of a person centered system of care that achieves improved outcomes and better services for recipients, as well as value for state Medicaid programs.
The Health Home is an enhanced service delivery model that promotes a better patient experience and better results than traditional care. The Health Home has many characteristics of the Patient-Centered Medical Home but is customized to meet the specific needs of Medicaid recipients with chronic medical conditions or behavioral health conditions.
Health Homes must provide six federally mandated Core Services:
- Comprehensive Care Management,
- Care Coordination
- Health Promotion
- Comprehensive Transitional Care
- Patient and Family Support
- Referral to community and support services
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.
Why is South Dakota implementing Health Homes?
South Dakota is implementing 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,
The work began as a recommendation of the Medicaid Solutions Workgroup. The Medicaid Solutions Workgroup, convened by Governor Dennis Daugaard during legislative session 2011, was tasked with identifying ways Medicaid could realize cost savings and better serve recipients. The Final Report of the Medicaid Solutions Workgroup can be viewed here: Final Reports of the Medicaid Solutions Workgroup.
In April 2012, the Department of Social Services convened a Health Home Workgroup to guide the process of evaluating and implementing Health Homes. The Health Home Workgroup concluded its work in October 2012. Information considered included federal requirements, other states’ Health Home models, SD Medicaid diagnostic and claims data, and other research.
Who is eligible for Health Homes?
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:
- 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).
- Recipients who have a Severe Mental Illness or Emotional Disturbance
Why not call it a Patient Centered Medical Home instead of a Health Home?
The Health Home terminology is used by the Centers for Medicaid and Medicare (CMS), and driven by federal language in the Affordable Care Act (ACA). While most of the services provided by a Health Home are similar to those provided by a patient center medical home, such as comprehensive care managed, care coordination, referral to community services and a focus on Health Information Technology, Health Homes are designed to serve a different population as required by ACA. The patient-centered medical home is population based while the Health Home focuses on Medicaid recipients. Eligible recipients must meet eligibility requirement outlined above.
Where are Health Homes located?
Health Homes are located where there are qualified designated providers are willing to serve the needs of those eligible. A list of Health Home providers is locaed online.
Who provides of Health Home Services?
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.
What do providers need to do to become a Health Home Provider?
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
How are providers reimbursed for Health Home Services?
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.