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Prior Authorization

Prior Authorization Request Services and Forms

NICU Transfers Out Of State

To be medically necessary, the covered service must meet the following conditions (ARSD 67:16:01:06.02):

  • It is consistent with the recipient's symptoms, diagnosis, condition, or injury;
  • It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group;
  • 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;
  • It is not furnished primarily for the convenience of the recipient or the provider; and
  • 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 prior authorization request form and documentation to:

Western South Dakota Eastern South Dakota

DSS, Division of Medical Services
Nurse Consultant
510 N Campbell, PO Box 2440
Rapid City, SD 57709
Phone: 605-394-1740
Fax: 605-394-2699

DSS, Division of Medical Services
Nurse Consultant
811 E. 10th Street Dept. 8
Sioux Falls, SD 57103-1650
Phone: (605) 367-7601
Fax: (605) 367-5253