Prior Authorization Request Services and Forms

Negative Pressure Wound Therapy Pumps V.A.C. (DME)

The Prior Authorization Request Form and 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):

• 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.

Documentation Requirements for Prior Authorization Requests:

• General Prior Authorization Request Form
• Physician’s prescription
• Applicable medical records or evaluation to meet above requirements.

Fax or Mail completed forms and documentation 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