Prior Authorization Request Services and Forms
Long Term Acute Care
The Prior Authorization Request Form is to be completed by the prescribing physician for all covered services requiring prior authorization for Medical Assistance Program eligible recipients.
This form is to be used by providers as written documentation to support medical necessity and must be completed and maintained in the patient’s medical record prior to submitting a claim to the South Dakota Medical Assistance Program.
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:
Mail or fax your completed form and documentation to:
DSS, Division of Medical Services
811 E. 10th Street Dept. 8
Sioux Falls, SD 57103-1650
Phone: (605) 367-7601
Fax: (605) 367-5253