Prior Authorization Request Services and Forms

Skilled Home Care Services / Private Duty Nursing

The South Dakota Medical Assistance Program covers medically necessary Skilled Home Care. These services may be performed by or under the supervision of a Medicare-certified Home Health Agency or licensed professional nurse pursuant to the plan of care developed in collaboration with the primary care provider. The intent is to allow/maintain the care of individuals in their place of residence, as long as it is safe to do so. Skilled professional services include the provision of direct care and the teaching, delegation and supervision of others who provide tasks of care to clients.

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.

Home Health Care Services Versus Private Duty Nursing Services

Home Health Care Services - Nursing services under the mandatory home health benefit must be provided inside the home. Such services are defined in 42 CFR 440.70(b)(1) as part-time or intermittent. Home health care services that meet ARSD 67:16:05 for adults and ARSD 67:16:11:03.19 for individuals under the age of 21 may be provided without prior authorization from the Office of Medical Services.

Private Duty Nursing Services - The scope of optional private duty nursing services is broader than that of nursing services under the mandatory home health benefit. Under the private duty nursing benefit, nursing services can be offered on a more continuous basis. Federal regulations define private duty nursing services as more individual and continuous care than is available from a visiting nurse. Private duty nursing services and extended home health aid services must be prior authorized by South Dakota Medical Assistance Care Managers under ARSD 67:16:11:03.20 - 22. These administrative rules define where home health nursing services end and private duty nursing services begin.

Rules and Policy Resources

• Home Health Care Administrative Rules *
• Extended Home Health Aide (EPSDT only) Revised Policy **

* Does not require prior authorization
**Requires prior authorization

Finding a Provider

• Medicare-Certified Home Health Agencies
• South Dakota Medical Assistance Home Health Providers
• Early Periodic Screening Diagnosis and Treatment (EPSDT) Private Duty Nursing Providers
• Enrolling as a South Dakota Medical Assistance Home Health Provider

Documentation Requirements for Prior Authorization Requests:

• Prior Authorization Request Form
• Medical record documentation

Mail or fax prior authorization request form and documentation to: