Provider Information

Prior Authorization Request Services and Forms

Residential Treatment Facility

For Adolescents authorized by the Medical Assistance Care Manager and are not in the custody of the State of South Dakota.

The South Dakota Medical Assistance Program provides coverage of treatment services in licensed group and residential treatment facilities for individuals who have behavioral or emotional problems requiring intensive professional assistance and therapy in a highly structured, self-contained environment.

Services must be provided by a provider licensed by the Department of Social Services (South Dakota Medical Assistance State Plan, Supplement to Attachment 3.1-A). The referring agency/person is responsible for identifying if the individual seeking services has current Medical Assistance eligibility or is in the process of seeking eligibility prior to requesting the authorization.

In-State

Provider Enrollment Application: Medical providers must submit required documentation as indicated on the application form.
Provider Agreement
W-9 Form
Direct Deposit Form
Ownership Disclosure Form

Out-of-State

Provider Enrollment Application: Medical providers must submit required documentation as indicated on the application form.
Provider Agreement
W-9 Form
Direct Deposit Form
Ownership Disclosure Form

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.

Attestation Form

Managed Care: Individuals covered under the Medical Assistance Managed Care Program must present a referral (purple) card from their Primary Care Provider (PCP) to the residential treatment facility.

Prior Authorization Required: Treatment services in residential treatment facilities must be prior authorized by the Medical Assistance Care Manager prior to admission to be considered a covered service under the Medical Assistance Program for those adolescents who are not under the care and custody of the State of South Dakota or are not eligible for IV-E funding. Prior Authorization is given by the State office of Department of Corrections (DOC) and Child Protection Services (CPS) for children under their care and custody.

Residential Treatment Prior Authorization Criteria: Authorization for residential treatment is based upon determination that the following criteria are met:

The services are medically necessary Administration Rule of South Dakota (ARSD) 67:16:01:06.02;
Ambulatory care resources in the community do not meet the treatment needs of the individual;
Proper treatment of the individual’s behavioral/emotional problems requires professional assistance and therapy in a highly structured, self-contained environment; and
The services can be expected to improve the individual’s emotional/behavioral condition or prevent further regression.

Documentation Necessary For The Prior Authorization Determination: Social history to include current behaviors that are prompting the request for residential placement must be submitted and any of the following that are applicable:

Current psychological evaluation including diagnosis (within the past 12 months).
Summary of other therapies/treatments that have been attempted including outcomes and recommendations.
School referral and summary of behaviors during school.
Discharge summaries from acute inpatient psychiatric hospitalizations.

Continued Stay Authorization Of Residential Treatment:
The prior authorization will be given for a specified time period. To request continued authorization the facility must submit, to the Medical Assistance Care Manager, a case service plan and progress updates on a quarterly basis, or as requested. It is the responsibility of the referral agency/person to insure that the documentation for continued stay is being provided to the Medical Assistance Care Manager in a timely manner and to notify the Care Manager of discharge dates or any change in the recipients status i.e., hospitalization, runaway, extended leave, etc.

Continued Stay Requirements:

The individual is actively participating in the treatment;
Progress on treatment goals is evidenced at least quarterly through the case service plan and/or progress update; and
The individual continues to exhibit behaviors/emotions that cannot be managed in a less restrictive environment.

Failure to comply with the requirements for continued stay will result in termination of coverage.

OUT OF STATE RESIDENTIAL TREATMENT
ADMISSION POLICY

Prior Authorization Required: Prior authorization must be given as follows when requesting out of state residential treatment or out of state residential treatment and tuition:

When requesting coverage of only the treatment service in a residential treatment facility:

Follow the process listed above for the Medical Assistance residential treatment prior authorization from the Medical Assistance Care Manager and

Submit documentation of denial from in-state residential treatment facilities and/or rationale for out of state placement.

When you are requesting coverage of the residential treatment service and tuition by the Auxiliary Placement Program in a residential treatment/group home facility:

Prior authorization must be obtained from the State Placement Committee by submitting a Placement Review Committee Referral form and an Application for Admission form to the Auxiliary Placement Program. Both of these forms are available through the Auxiliary Placement Program.

Additional documentation to accompany these forms must include the following:
1. Denials from in-state residential treatment facilities;
2. Current psychological evaluations;
3. Summary of other therapies/treatments that have been attempted including outcomes and recommendations;
4. Discharge summaries from acute inpatient psychiatric hospitalizations.

Claim Requirements: A claim for residential treatment for individuals under the age of 21 years may be submitted by an enrolled South Dakota Medical Assistance Provider if the treatment has been prior authorized. The claim must be submitted on a HCFA 1500 Form and must contain the following information:

The recipient's full name as it appears on the medical assistance identification card.

The recipient's medical assistance identification number from the recipient's medical assistance identification card.

Third-party liability information required under chapter 67:16:26 of the Administrative Rules of South Dakota.

Date of service.

Place of service (56).

Type of service (9).

The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge.

Units of service furnished if more than one.

The applicable South Dakota Medical Assistance procedure codes:
- H5050, Residential Treatment authorized by CPS & DOC
- H5040, Residential Treatment authorized by Medicaid Care Manager

The provider's name, address, telephone number and residential treatment provider number.

The signature of the provider or provider's representative and the date of signature.

The primary care provider number.

The prior authorization number.

A separate claim form must be used for each recipient.