Prior Authorization Request Services and Forms
CCHS Medically Complex / Rehab
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):
67:16:43:04. Admission requirements. Admission to a medically complex program is a covered service if the following criteria are met:
- Medical documentation substantiates that the service is medically necessary. Medical documentation includes a diagnosis, a complete medical history, copies of progress notes from physicians or other professionals providing care or services, laboratory tests, X rays, physician orders and a treatment plan outlining the needed care, and any other documentation which may be necessary to determine medical necessity for the child's admission;
- Home health care is not a viable option as determined by the department based on the child's medical needs, the availability of home health services, and cost effectiveness;
- The facility has notified the child's school district that the child has been referred to the facility for services and may be in need of an educational program;
- The cost of care does not exceed the cost of care in the child's home; and
- Professional nursing services are necessary on a 24-hour basis and the child requires at least two of the following services:
- Intravenous medications more than twice a day which must be administered by a registered nurse;
- Drug therapy stabilization which requires skilled monitoring on a 24-hour basis;
- Nutritional therapy during an unstable period;
- Alternative nutritional feeding, such as nasogastric or gastrostomy feeding, during an unstable period;
- Tracheostomy care during an unstable period;
- Colostomy or ileostomy care during an unstable period;
- Skilled skin care and monitoring for the treatment of a decubitus ulcer;
- Monitoring of oxygen saturation when oxygen is being administered;
- Skilled nursing observation and assessment following casting or surgeries;
- Direct paraprofessional care for more than eight hours a day which is supervised by a medical professional;
- Peritoneal dialysis during an unstable period;
- Infectious disease care during an unstable period;
- Use of a ventilator during an unstable period; or
- Professional monitoring to manage end stage disease process.
For purposes of this rule, an unstable period is that period of time necessary for a child to return to a medically stable state following a disease process, illness, or surgery.
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