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Prior Authorization

Prior Authorization Request Services and Forms

Psychiatric Residential Treatment Facilities (PRTF)

Intensive Residential Treatment Facilities (IRT)

For a complete review of applicable ARSD please visit CHAPTER 67:16:47 RESIDENTIAL TREATMENT FOR CHILDREN

http://legis.state.sd.us/rules/DisplayRule.aspx?Rule=67:16:47

67:16:47:04. Treatment as a covered service -- Conditions that must be met. Treatment at an eligible facility is a covered service if the following conditions are met:

  1. The individual is under the age of 21 or, if treatment began before the individual reached the age of 21, the treatment may continue until the date it is no longer needed or the date the individual reaches the age of 22, whichever occurs earlier;

  2. The state review team has determined that the conditions of § 67:16:47:04.02 have been met;

  3. The certification team has certified that the requirements contained in § 67:16:47:04.04 have been met;

  4. The services are expected to improve the individual’s emotional and behavioral condition or prevent further regression; and

  5. The individual is eligible for medical assistance under article 67:46.

The referring source shall gather and supply to the department the documentation necessary to determine eligibility.

67:16:47:05. Prior approval required for admission. Before an individual may be admitted to a facility for treatment, the certification team must approve the individual’s admission to the facility. Approval is based on a review of the following documentation:

  1. The individual’s social history that includes past and current behaviors that have prompted the request for admission to a residential facility;

  2. A psychological evaluation and diagnosis that was completed within the past 12 months;

  3. A summary of the individual’s behaviors during school from the individual’s school district, if available;

  4. Copies of the discharge summaries from previous acute inpatient psychiatric hospitalizations, if applicable;

  5. A summary of outpatient care services that have been provided, including outcomes and recommendations; and

  6. An alcohol and drug screening assessment, if available.

The placing agency shall gather and supply to the department the required documentation.

For emergency admissions, the certification team shall complete its review on the first working day following the date of admission into the residential treatment center.


Documentation Requirements for Residential Treatment Facility Prior Authorization Requests:

  • South Dakota PRTF Referral Form
  • The individual’s social history that includes past and current behaviors that have prompted the request for admission to a residential facility;
  • A psychological evaluation and diagnosis that was completed within the past 12 months;
  • A summary of the individual’s behaviors during school from the individual’s school district, if available;
  • Copies of the discharge summaries from previous acute inpatient psychiatric hospitalizations, if applicable;
  • A summary of outpatient care services that have been provided, including outcomes and recommendations; and
  • An alcohol and drug screening assessment, if available.

Send Prior Authorizations Requests to:

DSS, Auxiliary Placement
700 Governors Drive
Pierre SD 57501
Phone: 605-773-3448
Fax: 605-773-7183

Requirements for Continued Stay in Residential Treatment Facilities:

CHAPTER 67:16:47 RESIDENTIAL TREATMENT FOR CHILDREN

http://legis.state.sd.us/rules/DisplayRule.aspx?Rule=67:16:47

67:16:47:08. Requirements for continued stay. An individual’s continuous and uninterrupted stay in a facility is a covered service if the certification team determines, based on the child’s progress report required by § 67:42:08:07 or 67:42:15:11, that all of the following conditions are met:

  1. The individual is actively participating in the treatment;

  2. The individual continues to require the authorized level of care and is not able to function or use outpatient care as reflected in the physician’s, nurse’s, or auxiliary staff’s notes;

  3. The individual is complying with the recommendations made by the treatment team; and

  4. The individual’s daily progress notes show improvement towards the goal of discharge.

Documentation Requirements for Continued Stay to be submitted by provider:

The Residential Treatment Facility provider may mail this documentation and Continued Stay Form to:

South Dakota Foundation for Medical Care
2600 West 49th Street, Suite 300
Sioux Falls, SD 57105