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Prior Authorization

Prior Authorization Request Services and Forms

Mental Health Visits for children under 2 years of age

This is the procedure for community mental health centers funded through the Department of Human Services (HCPC code H2021)

Documentation Requirements for Prior Authorization Requests:

  • Child’s name
  • Child’s Date of Birth
  • SD Medicaid ID # (if eligible)
  • A description of the presenting problems
  • Diagnosis or diagnostic impression
  • Planned course of treatment

*Any services provided prior to the waiver approval will not be covered services.


Mail or fax your completed form and documentation to:

Division of Mental Health
E Hwy 34, Hillsview Plaza
c/o 500 Capitol Ave.
Pierre, South Dakota 57501-5070
Phone: (605) 773-5991
Fax: (605) 773-7076