Prior Authorization Request Services and Forms

Speech Generating Device (DME)

The Prior Authorization Request Form which includes the Certificate of Medical Necessity for Durable Medical Equipment (DME) is to be completed by the prescribing physician for all types of covered durable equipment ordered for Medical Assistance Program eligible recipients. This form is to be used by DME suppliers 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.

These forms 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.

To be medically necessary, the covered service must meet the following conditions (ARSD 67:16:01:06.02):

67:16:29:02.07 Augmentative communication device -- Modification -- Prior authorization -- Required documentation.

67:16:29:02.08 Requirements for supervising speech pathologist.

67:16:29:02.09 Augmentative communication device -- Assessment requirements.

67:16:29:02.10 Augmentative communication device -- Maintenance and repair.

67:16:29:02.11 Augmentative communication device -- Purchase of warranty.

Documentation Requirements for Prior Authorization Requests:

• Prior Authorization Request Form
• Evaluation by a speech pathologist meeting requirements in above rules

Fax or Mail completed forms, documentation, and evaluation to:

DSS, Division of Medical Services
Nurse Consultant
811 E. 10th Street Dept. 8
Sioux Falls, SD 57103-1650
Phone: (605) 367-7601
Fax: (605) 367-5253