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:

• Inpatient Prior Authorization Request Form
• Medical record documentation

Mail or fax prior authorization request form and documentation to: