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