April 2013

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Over the County Treatment for Head Lice

The Medicaid Pharmacy & Therapeutics Committee wishes to remind providers that Medicaid covers over the counter treatments for head lice (ex., Rid, Nix) with a prescription. These over the counter treatments do not require prior authorization.   Prescription treatments, including Lindane, Natroba, and Sklice do require prior authorization.  Prior authorization requires demonstration that the patient has tried an over the counter product unsuccessfully.

Inpatient Hospitalization notification

South Dakota hospitals have been reporting to South Dakota Medicaid each time a recipient is hospitalized for an acute care admission for six consecutive days since October 2011. This requirement was extended to include hospitals within 50 miles of the South Dakota border and Bismarck, ND effective February 25, 2013.

Since initial implementation of this requirement, we have seen a steady decrease in the number of Medicaid recipients in the hospital for six days or more reported to Medicaid, as well as improved communication between Medicaid and the hospitals which results in improved patient outcomes. When hospitals report an inpatient stay of six consecutive days, a Registered Nurse with South Dakota Medicaid tracks the case. The RNs are available to provide guidance and information that will help the facility plan for timely and appropriate care transitions out of acute care. For more information visit

Employee Spotlight

Dr. Mary Carpenter serves as the Medicaid Medical Director and medical consultant to the Division of Medical Services. In addition to acting as a resource to staff on a variety of topics, Dr. Carpenter serves on the Disability/Incapacity Team as a medical consultant, works with the nursing staff to advise on prior authorization determinations, and reviews policies regarding coverage. She functioned in that capacity for the past few years on a part-time basis while still actively practicing Family Medicine in Winner, SD. At end of November Dr. Carpenter curtailed her practice in Winner to one day a week, working in satellite clinics in Burke and Bonesteel. Her role with the State expanded, however, as she began serving as the Medical Director for Corrections Health and consultant to Department of Health.

Dr. Carpenter attended undergraduate education at Creighton University in Omaha and Medical School at USD School of Medicine, and residency training in Family Medicine in Tulsa, Oklahoma. After finishing her residency she moved to Winner and practiced there full-time from 1984 until October 2012. She has 3 grown children and 3 grandchildren that she plans to be able to visit more often now - probably much to their chagrin!

New Employees

Abby Breyfogle

As the Managed Care Program Assistant, Abby assists approximately 92,000 managed care recipients in selecting or updating their primary care physician. Abby also works closely with the Managed Care team to identify efficiencies, improve processes, and help ensure quality outcomes. Abby moved to Pierre in February of 2011 with her husband. In December, they welcomed their first child - a daughter. They also have a chocolate lab named Ammo.

Tracy Peterson

Tracy began in Medical Services as a temporary worker in the Managed Care area. We are pleased to have Tracy as a permanent member of the Provider Enrollment team. Tracy helps providers through the enrollment process by ensuring all required paperwork and processes have been completed. When she's not talking to providers, Tracy is the busy mother of four children who enjoys exploring the great outdoors.

Laura Louder

Laura Louder has rejoined the Telephone Services Unit of Medical Services. Laura had previously worked in Medical Services for 10 years. She is the lead worker on nursing home claims and assists in all claim types. Laura has lived in Hughes and Stanley counties all of her life and currently lives in Draper SD, home of the famous Busted Nut Cafe. Laura has been married to her husband for nearly 26 years and they have 3 children and 6 grandchildren.

Important Contact Numbers

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Telephone Service Unit for Claim Inquires:

In State Providers: 1-800-452-7691

Out of State Providers: 605-945-5006

Provider Response (Enrollment and Update Information): 1-866-718-0084

Medical Assistance for Recipients: 1-800-597-1603

Dental Claim and Eligibility Inquiries: 1-800-627-3961

Managed Care Updates: 605-773-3495

Pharmacy Prior Authorization: 1-866-705-5391

Medical & Psychiatric Prior Authorization:

Recipient Premium Assistance: 1-888-828-0059

Welfare Fraud Hotline: 1-800-765-7867

Medicare: 1-800-633-4227

Division of Medical Services Fax: 605-773-5246

Provider Enrollment Fax: 605-773-8520

2013 Legislative Session

Legislative session is always a busy time for the Department of Social Services, and 2013 was no exception. The Department was involved in several pieces of legislation, including bills presented by the Child Support Commission, the Behavioral Health Workgroup chaired by Lieutenant Governor Matt Michels, and two Licensing Boards.

The Department is currently working hard to implement the FY2014 budget appropriated by the legislature, which will go into effect on July 1, 2013. The Department is also working to distribute the one time provider bonuses appropriated for FY2013. More information will be shared with providers over the coming weeks.

Medicaid State Plan Available on Web

We are pleased to announce that the South Dakota Medicaid State Plan is now available on the DSS website. The Medicaid State Plan is a contract between the state of South Dakota and the Federal government describing how South Dakota administers its Medicaid Program.

You can access the Medicaid State Plan via this link:

Questions about the State Plan or its contents can be addressed to Ann Schwartz, Deputy Director of Medical Services, at 605-773-3495.

DSS Gears Up for Implementation of Health Homes

DSS kicked off the implementation phase of Health Homes on April 4th by conducting a Webinar that walked interested providers through the application process and program expectations. Health Homes are part of a person centered system of care that achieves improved outcomes for recipients and better services and value for state Medicaid programs.

If you want to learn more about the Health Home initiative and the provider application process, but were unable to participate in that Webinar, the Health Home Provider Application and other materials including the Webinar are posted at the following website:

If a provider is interested in providing Health Home services beginning July 1, 2013, a completed provider application must be submitted to DSS by May 1, 2013. Each participating Health Home location will need to complete an application. DSS will review the applications and notify approved locations in mid-May. DSS will coordinate with approved locations to schedule an on-site Health Homes orientation to be held in May or early June.

Information about Health Homes can be found on the DSS website at

Questions about Health Homes can be addressed to Kathi Mueller at (605) 773-3495.

South Dakota Continues to Improve Our Payment Error Rate

South Dakota received the results of CMS's 2011 Payment Error Rate Measurement (PERM) Project. Due to the previous low PERM finding, South Dakota obtained an exemption from the Medicaid Recovery Audit Contractor (RAC) review through May 2013. As a result of the most recent PERM findings we have formally requested another exemption from the RAC review process from CMS and are awaiting their response.

Although we are very pleased with our most recent PERM results, we want providers to be aware of the errors that resulted in recoveries from the last PERM review, so providers can pay close attention to these types of errors for the next PERM cycle review to help prevent any additional findings in these areas.
The following errors resulted in recovery of overpayments, and in some cases expanded post payment reviews that resulted in additional recoveries:

  • Nursing homes failure to maintain required, and properly completed, physician exam notes for each resident.
  • School districts that didn't retain the daily treatment notes required of the therapist(s) providing therapy services under each child’s individual education plan (IEP). 
  • Insufficient or inaccurate documentation

Providers are asked to take note of these findings and review their policies and procedures to continue a low error rate. We encourage providers to have all staff review applicable Administrative Rules of South Dakota and provider billing manuals upon hire and at least annually following to ensure continued compliance with South Dakota Medicaid's requirements.

Primary Care Provider Enhanced Payments

South Dakota is actively working with providers to implement enhanced payments for certain services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children Program required under the Affordable Care Act. Enhanced payments will not be made until we receive approval of the State Plan Amendment from the Centers for Medicare and Medicaid Services. Additional communication will be sent when claims begin processing with the enhanced payments.  These payments do not apply to all providers.  If you are unclear whether or not you are eligible, please review additional information, including the list of frequently asked questions and self-attestation form online.

Provider Enrollment for Ordering, Referring, and Prescribing Providers

The Division of Medical Services is reviewing its current enrollment practices and will be implementing changes in order to be compliant with federal Affordable Care Act requirements.  Among the changes includes a requirement that NPIs for all ordering, referring, and prescribing providers are enrolled with SD Medicaid and populated on the claims for services. If either condition is not met, claims are required to be denied. The Division of Medical Services is evaluating the ability to offer a streamlined enrollment process for providers only prescribing pharmaceutical products.  Requirements depend on provider type and include the collection of application fees for institutional providers, possible site visits prior to making a provider enrollment determination, the revalidation and collection of disclosure information such as provider agreements no less than every three to five years, and monthly screening requirements.

Providers can begin preparing for these changes by ensuring their internal processes are able to identify providers not yet enrolled with SD Medicaid prior to claims submission.  Provider enrollment records in SD MEDX at both the billing and servicing level should be reviewed for accuracy including current licensure and taxonomy, notation of an end date for any providers no longer with the group or facility, validation of servicing locations, and population of current managing employee data within the ownership step of billing entities' SD MEDX record. These changes will not modify the requirement for out-of-state providers to have a claim for service before enrollment can be approved.

Additional communication will be shared as the Division of Medical Services progresses with these requirements.  For additional information on the federal requirements, refer to 42 CFR Parts 424 and 455.

Electronic Health Record Incentive Payment Program update

South Dakota's Electronic Health Record (EHR) Incentive Payment Program continues to play an important role in establishing critical health information technology designed to reduce costs, improve care and advance coordination across healthcare systems, leading to better health outcomes and healthier lives. 

Under South Dakota's EHR Incentive Payment Program, eligible professionals (EPs) and eligible hospitals (EHs) can receive incentive payments the first year by simply adopting, implementing or upgrading a certified electronic health record technology. They do not have to meet the meaningful use criteria the first year, but for the subsequent years, they would have to demonstrate meaningful use.

South Dakota has distributed $12.5 million in incentive payments to 158 EPs and EHs since disbursement of payments started in March of 2012.

As required by the Meaningful Use Stage 2 rules announced in the fall of 2012, South Dakota has implemented changes to the patient volume calculation within the attestation portal. The CHIP population will now be included in the calculation of the patient volume and the consecutive 90-day reporting period will be more flexible. The new functionality was deployed February 22, 2013.

As providers aim to meet meaningful use, they should be aware of the additional Stage 2 changes announced last fall regarding the core objectives and menu measures.

  • The EPs for Stage 1 will have to meet 20 total objectives with 15 being core objectives and meeting 5 of 10 menu objectives. For Stage 2, EPs are still required to meet 20 total objectives but will have to meet 17 core objectives and 3 out of 6 menu objectives.
  • The EHs and CAHs for Stage 1 will have to meet 19 total objectives with 14 being core objectives and meeting 5 of 10 menu objectives.  For Stage 2, EHs and CAHs are still required to meet 19 total objectives but will have to meet 16 core objectives and 3 out of 6 menu objectives.

As described below, the Clinical Quality Measures (CQM) reporting will remain the same for 2013 but have changes in 2014 and beyond.

Reporting Clinical Quality Measures (CQM) in 2013 will remain the same as finalized in Stage 1:

  • EPs will continue to report on 6 of the 44 measures
    • 3 core/alternate core
    • 3 additional measures for EPs
  • EHs and CAHs will continue to report the 15 measures

Reporting Clinical Quality Measures (CQM) in 2014 and beyond:

  • EPs must report on 9 of the 64 CQMs
  • EHs and CAHs mush report on 16 of the 29 approved CQMs

For more details on the Stage 2 changes, visit the CMS website at

If you have any questions regarding SD Medicaid EHR Incentive Payment Program, please call 605.773.3495 or email your questions to

South Dakota QuitLine Services
(Article courtesy of South Dakota Department of Health)

Tobacco use is the leading preventable cause of death in the United States (US).1 Recent data indicate that 23% of South Dakota (SD) adults are current smokers.2 Among US adults who are enrolled in Medicaid, rates of smoking prevalence are more than two times higher than the overall adult population.3 Smoking is costly to the Medicaid program. Using 2004 values, it was estimated that $68 million of annual Medicaid expenditures in SD (i.e., 11% of the total) were attributed to smoking.3

Effective tobacco cessation treatment is available and highly accessible. The South Dakota Department of Health QuitLine offers a toll-free telephone service for tobacco users. Callers who request services are offered up to five proactive coaching sessions delivered by trained health coaches. Coaching participants have access to nicotine replacement therapy (NRT) in the form of patches, gum and lozenges or the cessation medications bupropion and varenicline at no cost. Tobacco dependence is a chronic disorder, and often multiple attempts are needed before the quit is maintained. Callers are eligible to enroll in SD QuitLine services on a yearly basis as needed to quit. Priority populations, including callers enrolled in Medicaid, pregnant women, youth callers, spit tobacco users, and American Indian callers, are eligible to re-enroll more frequently.

The SD QuitLine is effective. Among individuals who requested services in 2011, 43% reported no tobacco use at seven months follow-up. Among individuals enrolled in Medicaid, 35.6% reported no tobacco use (see Table). Medicaid enrollees who did not quit smoking cited stress as the major reason (50%).

Despite the effectiveness, few healthcare providers have the time, expertise, or resources needed to provide tobacco cessation counseling. However, provider encouragement can motivate tobacco users to quit. Providers at all levels can: (a) ask about tobacco use, (b) advise patients to quit, and for patients who are interested (c) refer to the SD QuitLine. For more information, or to refer a patient for SD QuitLine services, please call 1-866-737-8487 or visit



% Response

Quit Rate

95% CI

Medicaid Recipients




30.3% - 41.2%

American Indian Callers




32.9% - 51.0%

Spit Tobacco Users




42.5% - 56.1%

Youth Callers




20.2% - 88.2%

Pregnant Callers




20.4% - 73.9%

Non-Priority Population




41.3% - 45.5%

  • Danaei, G., Ding, E.L., Mozaffarian, D., Taylor, B., Rehm, J., et al. (2009). The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med 6(4): e1000058. doi:10.1371/journal.pmed.1000058.
  • Centers for Disease Control and Prevention (CDC). (2011). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.
  • Armour, B. S., Finkelstein, E. A., & Fiebelkorn, I. C. (2009). State-level Medicaid expenditures attributable to smoking. Preventing Chronic Disease, 6(3), A84. Retrieved from


Comments or questions?
Contact Medical Services

South Dakota Department of Social Services

Division of Medical Services
700 Governors Drive
Pierre, SD 57501
Phone 605.773.3495

Fax 605.773.5246

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