Lynne A. Valenti
Cabinet Secretary

DSS Mobile Logo Mobile Menu Button

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.
  • DHS CHOICES Waiver
    This manual details mandatory fields required for billing on the HCFA 1500 for DHS CHOICES Waiver Providers. This billing guidance is effective as of Dec. 1, 2016.
  • 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.

License for Use of Physicians' Current Procedural Terminology (CPT)

End User Point and Click Agreement

Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2015 American Medical Association (AMA).

You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 515 North State Street, Chicago, IL 60610. Applications are available on the AMA website, http://www.ama-assn.org/go/cptExternal_Link.

Applicable FARS/DFARS restrictions apply to government use. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60654. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-l(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

AMA Disclaimer of Warranties and Liabilities
CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer
The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

Should the foregoing terms and conditions be acceptable to you, indicate your agreement and acceptance by clicking on the button labeled "I ACCEPT."

Point and Click License for Use of Current Dental Terminology (CDT™)
End User License Agreement

These materials contain Current Dental Terminology (CDT™), Copyright © 2015 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING ON THE BUTTON LABELED “I ACCEPT,” YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ON THE BUTTON LABELED “I DO NOT ACCEPT” AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, “YOU” AND “YOUR” REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website: http://www.ADA.org/.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. This product includes Current Dental Terminology ("CDT'"), which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Dental Association, 211 East Chicago Avenue, Chicago, Illinois, 60611. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-l(a) (June 1995) and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT IS PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESSED OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. NO FEE SCHEDULES, BASIC UNIT, RELATIVE VALUES, OR RELATED LISTINGS ARE INCLUDED IN CDT. THE ADA DOES NOT DIRECTLY OR INDIRECTLY PRACTICE MEDICINE OR DISPENSE DENTAL SERVICES. THE SOLE RESPONSIBILITY FOR THE SOFTWARE, INCLUDING ANY CDT AND OTHER CONTENT CONTAINED HEREIN, IS WITH XEROX STATE HEALTHCARE, LLC OR THE CMS; AND NO ENDORSEMENT BY THE ADA IS INTENDED OR IMPLIED. THE ADA EXPRESSLY DISCLAIMS RESPONSIBILITY FOR ANY CONSEQUENCES OR LIABILITY ATTRIBUTABLE TO OR RELATED TO ANY USE, NON-USE, OR INTERPRETATION OF INFORMATION CONTAINED OR NOT CONTAINED IN THIS FILE/PRODUCT. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End users do not act for or on behalf of CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. IN NO EVENT SHALL CMS BE LIABLE FOR DIRECT, INDIRECT, SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGES ARISING OUT OF THE USE OF SUCH INFORMATION OR MATERIAL.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, indicate your agreement by clicking on the button labeled “I ACCEPT.” If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click on the button labeled “I DO NOT ACCEPT” and exit from this computer screen.