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Prior Authorization

Prior Authorization Request Services and Forms

Mental Health visits beyond the coverage limit

67:16:41:11. Prior authorization. A mental health provider must have prior authorization from the department before providing any service listed in § 67:16:41:09 which will exceed the limits established in this chapter. Authorization is based on documentation submitted to the department by the mental health provider. The documentation must include the provider's written treatment plan, the diagnosis, and the planned treatment. Failure to obtain approval from the department before providing the service is cause for the department to determine that the service is a noncovered service.

The department may verbally authorize services; however, the department must verify a verbal authorization in writing before the services are paid.

Services which exceed the established limits are subject to peer reviews according to § 67:16:41:15.

CHAPTER 67:16:41


67:16:01:06.02. Covered services must be medically necessary. Services covered under this article must be medically necessary. To be medically necessary, the covered service must meet the following conditions:

  1. It is consistent with the recipient's symptoms, diagnosis, condition, or injury;

  2. It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group;

  3. It is provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition;

  4. It is not furnished primarily for the convenience of the recipient or the provider; and

  5. There is no other equally effective course of treatment available or suitable for the recipient requesting the service which is more conservative or substantially less costly.

Documentation Requirements for Prior Authorization Requests:

Mail or fax your completed form and documentation to:

Division of Medical Services
700 Governors Drive
Pierre, SD 57501
Fax 605-773-5246