Medical Services

Provider Information

Provider Enrollment Information and Forms

These forms are to be used by medical providers who wish to participate in the South Dakota Medical Assistance Program.

If you have any questions about these forms, contact Medical Services at (605) 773-3495. Mail your completed forms to:

  • Department of Social Services
    Division of Medical Services
    ATTN: Provider Enrollment
    700 Governors Drive
    Pierre, SD 57501-2291

Medical Assistance Provider Enrollment

Medical providers must complete the following forms to enroll in the Medical Assistance Program to provide Medical Assistance. The application contains questions that need to be answered completely and indicates other required documentation which must be submitted with enrollment forms. The agreement establishes contractual relations with the provider to ensure the provider adheres to rules and regulations established by South Dakota administrative rule and codified law.

In-State

Out-of-State

South Dakota Medical Assistance will enroll an out-of-state provider who has administered medical services to a South Dakota Medicaid recipient. Documentation of this medical service must be presented as a claim for services (CMS 1500 for professional services, an UB 04 for institutional services or a Universal Pharmacy Claim Form). Medical services must be provided to a South Dakota Medicaid recipient or the out of state provider will not be enrolled in our program. An exception to the policy will be granted to out of state providers who are within 50 miles of South Dakota’s borders.

Restraint and Seclusion Attestation Form

The Centers for Medicare and Medicaid Services (CMS) requires all State Medicaid Agencies to obtain an annual attestation form from all residential treatment facilities providing psychiatric services to individuals under age 21. This form ensures compliance, on the part of the facility, with the federal regulations that govern the use of restraint and seclusion as codified in 42 CFR §§ 483 Subpart G.

The attestation form must be completed and signed by an individual who has the legal authority to obligate the facility.

Formal Addendums to the South Dakota Medical Assistance Provider Agreement

These addendums serve as additional documents to the South Dakota Medical Assistance Provider Agreement for specific provider types. These forms establish contractual relations with the specific provider type to ensure the provider adheres to rules and regulations established by South Dakota Administrative Rule and Codified Law.

Mental Health Services Addendum

Wheelchair Transportation Addendum

School District Addendum

Addendum to the Provider Agreement to Participate in the South Dakota Medical Assistance PRIME Program (Managed Care) as a Primary Care Provider

Medical assistance providers who anticipate participating in the South Dakota Medical Assistance PRIME Program may use this Addendum to the Provider Agreement to enroll as a Primary Care Provider (PCP) in the Managed Care Program.

Electronic Media Provider Agreement

Used by medical providers who want to submit claims with the use of electronic media to the Medical Assistance Program.

Trading Partner Agreement

Used by medical providers when they are ready to submit claims and receive Remittance Notices electronically. Providers will need to acquire a clearinghouse/submitter/programmer who will have the ability to send, read and unscramble the electronic transmitted data. This document also reflects the standards for privacy and security as mandated by the Health Insurance Portability and Accountability Act (HIPAA) for electronic transactions.