Lynne A. Valenti
Cabinet Secretary

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Billing Manuals

Listed below is a series of billing manuals for enrolled South Dakota Medicaid providers. The manuals are designed for use as a guide for the preparation of claims. The manuals are not intended to address all rules and regulations of South Dakota Medicaid.

  • Dental Provider
    For questions relating to dental billing procedures, please contact South Dakota Medicaid’s contractor, Delta Dental of South Dakota at 1.877.841.1478.
  • Health Home Billing Manual
    This manual details the South Dakota Medicaid Policies for Health Homes including instructions for applying to be a Health Home, Claims Submission and Billing for Health Home Services, Rate Calculation and Methodology, Recipient Assignment, Enrollment and Disenrollment, Recipient Referral Process and Health Home Record Keeping Requirements.
  • Institutional Billing Manual
    This manual details South Dakota Medicaid policies relating to hospital, hospice and long-term care covered services, and reimbursement. Additionally, this manual contains step-by-step instructions to complete the CMS 1450 (UB-04) claim form according to South Dakota Medicaid rules.
  • Pharmacy Billing Manual
    This manual details South Dakota Medicaid policies relating to pharmacy services. This manual contains additional instructions regarding the universal pharmacy claim form and the Point-of-Sale (POS) system.
  • Prior Authorization Manual
    This manual contains the prior authorization criteria and documentation requirements for all services that require a prior authorization before payment from South Dakota Medicaid.
  • Professional Services Billing Manual
    This manual details South Dakota Medicaid policies relating to physician services; audiological testing and speech pathology; physical and occupational therapy; optometric services; telemedicine; family planning services, nurse midwife, nurse anesthetist, nurse practitioner or physician assistant’s services; ambulatory surgical centers; chiropractic services; durable medical equipment and nutritional therapy; EPSDT screening services; home health services; podiatry services; South Dakota Medicaid Managed Care Program; mental health services; school districts, Birth to Three and transportation. Additionally, this manual contains step-by-step instructions to complete the CMS 1500 claim form according to South Dakota Medicaid rules.

HIPAA Manuals

The administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) requires the United States Department of Health and Human Services to establish national standards for electronic health care transactions and national identifiers for providers, health plans and employers. South Dakota Medicaid is required by federal law to conform to the national standards. Listed below is a series of manuals detailing the situational data elements and plan-specific values that must be included in transactions that are transmitted electronically to South Dakota Medicaid.

Other Manuals

  • CMS RAI Manual
  • Administrative Hearings Procedure
    This manual is a guide to procedures used in contested cases before the South Dakota Department of Social Services Office of Administrative Hearings. It is intended to provider general information on procedures for both the individuals who have requested a hearing and Department representatives.