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Prior Authorization

Prior Authorization Request Services and Forms

Care Management Psychiatric Units

Care Management Regulations - Administrative Rule of South Dakota 67:16:40

Care Managers prior out-of-state psychiatric services.

West SD

Nurse Consultant
510 N. Cambell
PO Box 2440
Rapid City, SD 57709
Phone: 605-394-1740
Fax: 605-394-2699

East SD

Nurse Consultant
811 E. 10th St. Dept 8
Sioux Falls, SD 57103
Phone: 605-367-5444
Fax: 605-367-5253

In-state in-patient hospital psychiatric services are prior authorized by:

South Dakota Foundation for Medical Care
1323 South Minnesota Avenue
Sioux Falls, SD 57105
Phone: 605-335-3505
Toll Free: 1-800-658-2285

67:16:40:07. Admission requirements -- Psychiatric care. An individual's psychiatric care is a covered service under this chapter if the hospital received authorization for the admission under § 67:16:40:04 and the following conditions are met:

  1. A physician completed a medical assessment of the individual and had at least a telephone consultation with a psychiatrist. The psychiatric consultation or diagnosis must include a treatable mental health condition. An admission is not allowed on the basis of a previous diagnosis if symptoms associated with the diagnosis are not active at the time of the admission;

  2. Outpatient services have failed or are not available in the community, or available services do not meet the treatment needs of the individual;

  3. Treatment of the individual's psychiatric condition requires services on an inpatient basis under the direction of a physician, and there is an expectation that the individual will improve with psychiatric treatment of less than ten days;

  4. Inpatient services are expected to improve the individual's condition or prevent further regression so that the inpatient services will no longer be needed; and

  5. The individual meets one of the following criteria:

    1. Exhibits behavior which supports a reasonable expectation that the individual will inflict serious physical injury upon himself or others in the very near future, including a recently expressed threat which, if considered in light of its context or in light of the individual's recent previous acts, is substantially supportive of an expectation that the threat will be carried out;

    2. Exhibits psychotic behavior with hallucinations or delusions;

    3. Is admitted under the provisions of SDCL 27A-10-1 and 27A-10-2 for a 24-hour hold for an evaluation; or

    4. Experiences reactions or intolerances to medications which cannot be managed in an outpatient or medical floor setting.

67:16:40:11. Psychiatric admission requires psychiatric evaluation. Within 24 hours after an individual is admitted for inpatient psychiatric care, the hospital must have a psychiatrist complete a psychiatric evaluation of the individual. The evaluation must be included in the individual's medical record.

67:16:40:14. Requirements for continued stay -- Psychiatric care. An individual's continuous and uninterrupted stay in inpatient psychiatric care is a covered service if the care manager determines that the following criteria are met:

  1. The individual continues to be a danger to self or others and is not able to function or utilize outpatient care, as reflected in the physician's, nurse's, or auxiliary staff's notes;

  2. The individual is complying with the recommendations made through the care conferences; and

  3. The individual's daily progress notes show improvement towards the goal of discharge.

67:16:40:17. Criteria for terminating coverage -- Psychiatric care. An individual's psychiatric care becomes a noncovered service when the care manager determines that the conditions of § 67:16:40:07 are no longer met.