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Prior Authorization

Prior Authorization Request Services and Forms

Care Management For Rehabilitation Units

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

Care Managers prior authorize in-state and out-of-state rehabilitation

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

67:16:40:09. Admission requirements -- Rehabilitation care. An individual's admission to a rehabilitation unit is a covered service if the hospital received authorization for the admission under § 67:16:40:04 and the care manager determines that the following criteria are met:

  1. The individual's previous medical condition was functional;

  2. The individual is capable of weekly improvement in the activities of daily living;

  3. The individual's primary medical condition is stable; and

  4. The individual is able to participate in rehabilitation therapies and can demonstrate gains in functional abilities.

67:16:40:15. Requirements for continued stay -- Rehabilitation care. An individual's continued stay in a rehabilitation unit is a covered service under this chapter if the individual demonstrates weekly improvement in becoming independent in the activities of daily living and is complying with the recommendations made through the care conference.

67:16:40:18. Criteria for terminating coverage -- Rehabilitation. An individual's care in a rehabilitation unit becomes a noncovered service if the care manager determines that the individual meets any of the following criteria:

  1. The individual has reached potential in the current setting;

  2. The individual is functional;

  3. The individual's condition is stable to the point of receiving outpatient care or care in an alternative setting; or

  4. The individual is not complying with the recommendations made through the care conference.