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Prior Authorization

Provider Information

Prior Authorization Request Services and Forms

Nutritional Therapy

The Certificate of Medical Necessity for Nutritional Therapy is to be completed by the prescribing physician for all types of covered nutritional therapy ordered for Medicaid-eligible recipients.

This form is to be used by nutritional therapy suppliers (DME, physician or pharmacy) 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 Medicaid for payment.

Mail your completed form to:

Division of Medical Services
700 Governors Drive
Pierre, SD 57501
Phone: (605) 773-3495
Fax: (605) 773-5246

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