Prior Authorization

Enteral Nutrition for adults over 20 years old

Parenteral Nutrition

The Prior Authorization Request Form which includes the Certificate of Medical Necessity for Nutritional Therapy must be completed by the prescribing physician for all types of covered nutritional therapy ordered for Medicaid-eligible recipients.

Nutritional therapy suppliers (DME, physician or pharmacy) are to provide written documentation to support medical necessity and must complete the forms maintained in the patient's medical record prior to submitting a claim to Medicaid for payment.

To be medically necessary, the covered service must meet the following conditions:

• 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.

Requirements for Prior Authorization Requests:

• Prior Authorization Request Form
• Physician’s prescription

Submit the completed form to:

• Department of Social Services
  Division of Medical Services
  Nurse Consultant
  811 E. 10th Street Dept. 8
  Sioux Falls, SD 57103-1650

Chapter 67:16:42: Nutritional Therapy and Nutritional Supplements:

67:16:42:01     Definitions.

67:16:42:02     Enteral nutritional therapy and nutritional supplements for individual under 21 years of age.

67:16:42:03     Enteral nutritional therapy for individual 21 years of age and older.

67:16:42:04     Enteral nutritional therapy for individual 21 years of age and older -- Prior authorization required.

67:16:42:05     Parenteral nutritional therapy.

67:16:42:06     Parenteral nutritional therapy -- Prior authorization required.

67:16:42:07     Nutritional therapy and nutritional supplements -- Limits.

67:16:42:08     Services not covered.