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Prior Authorization

Prior Authorization Request Services and Forms

DME

All Durable Medical Equipment requests for children under age 21 that are medically necessary but fall outside coverage limits require prior authorization by the Department of Social Services.

67:16:01:06.02. Covered services must be medically necessary. Services covered under this article must be medically necessary. To be medically necessary, the covered service must meet the following conditions:

  1. It is consistent with the recipient's symptoms, diagnosis, condition, or injury;

  2. It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group;

  3. 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;

  4. It is not furnished primarily for the convenience of the recipient or the provider; and

  5. 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:

  • General Prior Authorization Request Form
  • Prescription
  • Medical records- any documentation that supports the request including but not limited to history of treatment, lab or test results, medical evaluations, and letters from providers.

Mail or fax your completed form and documentation to:

Department of Social Services
EPSDT Coordinator
700 Governors Drive
Pierre, SD 57501
Phone: 605-773-3495
Fax: 605-773-5246