Lynne A. Valenti
Cabinet Secretary

DSS Mobile Logo Mobile Menu Button

Frequently Asked Questions

Recipient Frequently Asked Questions

What is South Dakota Medicaid?

Medicaid is a federal and state-funded program providing health coverage for people who meet certain eligibility standards. If you are eligible, Medicaid will act as your insurance company and may pay for medically necessary services such as visits to the doctor, hospital, dentist, optometrist and chiropractor.

Am I eligible for Medicaid?

Eligibility for Medicaid depends on your income and circumstances. For more information, visit your Department of Social Services local office or check out your options for applying on our website.

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 Supplemental Security Income (SSI) payment are automatically eligible for Medicaid. If your child is no longer receiving a SSI payment, your child’s eligibility for Medicaid ends. The Social Security Administration determines eligibility for SSI 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.

What do I do if my name is spelled incorrectly or the date of birth is wrong on my Medicaid ID card?

Contact your Benefits Specialist at your local DSS office and provide him/her with the correct information. It will then be corrected in SD Medicaid’s records and you will be issued a new card. If you did not apply at a local office, please call 1.877.999.5612.

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 view covered services in the Medicaid Recipient Handbook.

Are check-ups/preventative care covered by Medicaid?

Yes. South Dakota Medicaid covers check-ups/preventative care.  The type of coverage differs by program type.

  • Full coverage adults: Yearly Well-Adult check-up and screenings, dental exams and cleanings, eye exam and immunizations.
  • Children: Yearly Well-Child check-ups, dental exams and cleanings, eye exam and immunizations.
  • Pregnant women: Prenatal exams and labs.

Can I go to the Emergency Room (ER)?

You may go to the ER for a serious health problem that may cause lasting injury or death, such as severe bleeding, chest pain, shortness of breath, severe pain, severe allergic reaction or loss of consciousness.

Do not go to the ER for treatment of a cold, cough or other minor illness or injury, your doctor can treat in the office or over the phone.  You will be responsible to pay the bill for non-referred, non-emergency services.

**Acute care and urgent care clinics offer instant care for acute illnesses and minor injuries on a walk-in basis. If you are enrolled in the PCP or the health home program, call your PCP or HHP before going to an acute care or urgent care clinic. 

Does Medicaid cover dental services?

Children and adults receive different dental coverage from Medicaid. Childrencoverage includes two exams and two cleanings per year, most dental sealants and other services to prevent tooth decay. Cavity fillings are also covered. Crowns, root canals, dentures, partials and other services to fix problems have limits, and most must be pre-approved. Talk to the dentist before treatment to know what is covered.

Braces and other orthodontic services are covered only when medically necessary for the worst cases. The child’s teeth must be bad enough to limit the ability to eat, chew and talk. All braces must be pre-approved. A replacement retainer is covered one time.

Adult coverage includes two exams and two cleanings per year. Cavity fillings are also covered. Crowns, root canals, dentures, partials and other services to fix problems have limits, and most must be pre-approved.

There is a $1,000 limit every year (July 1 – June 30) for covered dental services. You must pay for services over the $1,000 yearly limit. The limit does not apply to medically necessary emergency services or to dentures and partials. You can ask your dentist to seek pre-approval from Delta Dental of South Dakota before you schedule your dental work. Then you will know what will be covered and what portion of the bill you might be responsible to pay. Delta Dental of South Dakota can also tell you if the $1,000 yearly limit has been or will be reached. Call Delta Dental of South Dakota at 1.800.627.3961 if you have questions about pre-approval, payment or the $1,000 limit.

Do I need a Primary Care Provider (PCP)?

A PCP is a provider or clinic you see for most of your medical care. Recipients eligible for the following programs must participate in the Primary Care Provider Program:

  • Supplemental Security Income (SSI) recipients: blind, disabled people age 19 and older
  • Parent and other caretaker relatives
  • Children on Medicaid or Children’s Health Insurance Program (CHIP)
  • Pregnant Women

How do I select a PCP?

If you are required to participate in the Primary Care Provider Program, you will receive a letter shortly after you are approved for South Dakota Medicaid with instructions on how to choose your PCP. 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. You can also view a list of PCPs online and complete the Provider Selection Form online.

If you are required to participate in the Primary Care Provider Program and you do not choose a PCP, DSS will choose one for you. Contact DSS at 1.800.597.1603 if you have questions.

When should i make an appointment with my PCP?

DSS recommends scheduling your annual check-up or prenatal care with your new PCP so you can establish care.  If you have another illness, you should go to your PCP before seeing other providers.  Your PCP can write a referral for services they cannot provide.

Can I change my PCP?

Yes. You may change your PCP at any time by completing a PCP change form or calling 1.800.597.1603. Your new PCP will go into effect the first day of the following month.

I forgot the name of my PCP. What do I need to do now?

Contact your Benefits Specialist at your local DSS office or call 1.800.597.1603 with your Medicaid ID number.

Do I need a referral to see a provider other than my PCP?

Yes. Most services from another provider require a referral from your PCP. You should get a referral before receiving the service. This is true even if it is a specialist, hospital service (including any non-emergency ER service), or acute/urgent care visit. View the recipient handbook for a complete list of services that require a referral and services that do not. A referral can be made by your PCP via a telephone referral, physician order, prescription, referral card, or certificate of medical necessity.

Is a paper referral card required to see a provider other than my PCP?

No. A referral card is a tool that indicates the information required by the "referred to" provider. A referral can be provided in many ways; examples include a telephone referral, a physician order, a prescription, or a certificate of medical necessity.

Will Medicaid cover out-of-state services?

Services more than 50 miles from the South Dakota border require an out-of-state prior authorization.  See Out-of-State section below for more information about out-of-state prior authorizations.

I have Medicaid. Why am I still getting a bill?

There are many reasons you may get a bill. Do NOT ignore medical bills.
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 from your PCP if you are in the Primary Care Provider Program or Health Homes Program.
  • You did not get the service prior-authorized and the service requires a prior authorization.
  • The provider may have incorrect information and needs you to contact them in order to bill South Dakota Medicaid.
  • You did not provide your Medicaid card number.
    • Remember to provide your newborns Medicaid card number to both the hospital and the provider.

I have pregnancy only coverage.  What does Medicaid cover?

Pregnancy-only coverage only covers services related to or caused by the pregnancy. Please talk to your PCP or South Dakota Medicaid about whether a service will be covered if you are unsure. 

Routine dental and vision services are not covered in this program.  If you feel you have a health issue that may put you and your baby at risk, contact your PCP.

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.

Can I be reimbursed for travel to an appointment out of town?

The Non-Emergency Medical Travel Program reimburses travel to medical appointments outside your city of residence.  The program reimburses you for mileage and may reimburse you for meals and lodging on overnight travel over 150 miles from your city of residence.

How can I find a Medicaid dental provider?

Visit Insure Kids Now and enter the required information in their search engine. You can also call the Delta Dental Medicaid Referral Line at 1.800.627.3961.

My provider told me I have another type of medical insurance other than Medicaid. I DO 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 our system. If you did not apply at a local office, please call 1.800.597.1603.

If you need a prescription filled immediately, please call 1.800.597.1603.

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, the provider must be a SD Medicaid provider and obtain a prior authorization for out-of-state services.

In addition, if your child is in the Primary Care Provider Program, he/she will need to get a referral from his/her primary care provider.

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.

Are broken, lost, or stolen eyeglasses covered?

South Dakota Medicaid will replace eyeglasses that are broken beyond repair and are returned to the provider.  Children who have had their eyeglasses stolen or are lost, may receive a replacement pair. SD Medicaid will not cover lost or stolen eyeglasses for adults.

Does SD 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 eligible for one well-child check-up each year. A well-child check-up may be used as a sports physical.  Sports physicals not done during a well-child check-up are not covered.

What do I do if my prescription is NOT covered?

First check the Medicaid Recipient Handbook. If you are unable to determine why it was not covered you should talk to your pharmacist or doctor. If you still have questions you may call 1.800.597.1603.

Non-Emergency Medical Travel Frequently Asked Questions

What can I be reimbursed for?

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.

How do I know if I qualify for NEMT reimbursement?

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.

If I have a medical appointment within the city I live, can i get reimbursed?

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

Can I get reimbursed to travel to my Primary Care Provider (PCP) or health Home Provider (HHP)?

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.

If my PCP or HHP refers me to a medical specialty provider, do I need a copy of my referral card?

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

What do I need to do to get travel reimbursement to and from my medical appointment?

The Medicaid Non-Emergency Medical Travel 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.

NEMT Payment Authorization Form must also be completed to have your payments either direct deposited into your checking or savings account or onto an electronic debit card.

The form, along with any necessary documentation, may be turned in at your local Department of Social Services’ office, mailed directly to: Department of Social Services, Office of Finance/EBT, 700 Governors Drive, Pierre, SD, 57501, emailed to dss.ebtstateoffice@state.sd.us, or faxed to 605.773.8461.

If I have already completed the NEMT Payment Authorization form, do I need to complete the form again?

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.  

If I had to stay overnight due to my medical appointment, do you need a copy of my motel receipt?

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.

When will I receive my reimbursement?

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.  Please allow 6-8 weeks from the date your claim was received in our office to be processed. You will receive a Paid Claims Statement showing specific travel dates and amounts in the mail once your claim has been paid.

How or where can I get the Medicaid Non-Emergency Medical Travel Form?

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 1.866.403.1433.

After my appointment I realized that I forgot to have the medical provider sign the reimbursement form verifying my appointment, what can I do?

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.

Will I be reimbursed for meals for a same day medical trip?

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

Can I get reimbursed to travel to medical appointments out-of-state?

Medicaid covered services received more than 50 miles outside of the state of South Dakota, except Bismarck, ND, will require prior authorization by South Dakota Medicaid. 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 by South Dakota Medicaid 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.

Can lodging be paid by NEMT if one parent/guardian/escort stays in the hospital and the other parent/guardian/escort stays in a hotel room?

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

I have a hotel room booked and I do not want to lose my room but have to return home over the weekend. Can I keep my belongings in the room and still be reimbursed by NEMT?

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

Provider Frequently Asked Questions

How do I know which services require a prior authorization?

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

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 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.

Where can I find a paper enrollment application?

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

How long does it take to process new applications or updates to my record?

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.

Do I have to enroll individual providers?

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.

How long does my enrollment last?

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.

How can providers receive Remittance Advices (RA's)?

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.  To log onto the Provider Online Portal click here. For more information about how to access the portal please click here. For assistance and questions regarding the Portal providers may send an email to DSSonlineportal@state.sd.us or call 605.773.3495.

Do SD MEDX passwords expire?

SD MEDX passwords expire every 90 days and if not reset prior to expiration will require the listed contact on the enrollment record to request a password reset from the SD MEDX Provider Response Team via email: SDMEDXSecurity@state.sd.us.  

What kind of training is available for SD MEDX?

A variety of training materials are available at SD MEDX Training.

Existing providers can refer to Maintenance and revalidation.   

Where do I find an excluded provider list?

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

Health Homes

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

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.

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:

  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

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.

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 Health Home.

Who provides 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. 

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 located online.

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.

Out-of-State Prior Authorization Frequently Asked Questions

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.

What if a patient is already established with an Out-of-State provider?

Medical Records will be reviewed to examine the need for continued care with the out-of-state provider. Prior Authorization will be granted when there is a medical need for continued services with the out-of-state provider.

When the condition being treated has been determined to be stable and the same specialty is available in South Dakota, routine follow-up will not continue to be covered out-of-state.  A letter will be mailed to the recipient or guardian, as well as the provider to explain the next steps. One additional visit may be approved to allow the patient and doctor to discuss referral options or send any questions or concerns to SD Medicaid

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.

Recipients should not schedule travel until an authorization has been approved by SD Medicaid.

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 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 may 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.

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. Recipients should not schedule travel until an authorization has been approved by SD Medicaid.

If an 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.

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.

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.

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 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 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.

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.

Does this requirement apply to children in DSS custody?

No, children in DSS custody are exempt from this requirement.

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.

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 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.

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.

Inpatient Hospitalization 6-Day Notification Form Frequently Asked Questions

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?

Yes.

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?

Yes.

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.

Please click on the Contact Us tab at the top of the page and provide either a link or description of the page where you are encountering problems.