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Frequently Asked Questions

Recipient Frequently Asked Questions

What is South Dakota Medicaid?

Medicaid is a federal and state-funded program providing health coverage for people who meet certain eligibility standards. If you are eligible, Medicaid will act as your insurance company and may pay for medically necessary services such as visits to the doctor, hospital, dentist, optometrist and chiropractor.

Am I eligible for Medicaid?

Eligibility for Medicaid depends on your income and circumstances. For more information, visit your Department of Social Services local office or check out your options for applying on our website.

I just took my disabled child, who is on Supplement Security Income (SSI), to the doctor and was told he/she is not eligible for Medicaid. Why is this happening?

In South Dakota individuals who receive a Supplemental Security Income (SSI) payment are automatically eligible for Medicaid. If your child is no longer receiving a SSI payment, your child’s eligibility for Medicaid ends. The Social Security Administration determines eligibility for SSI payments.

When this happens you will receive a notice from DSS instructing you to contact the local office nearest you to explore other possible eligibility options.

If the payment ended, but you have since received another awards letter stating you are eligible for payment, it is possible DSS has not yet been notified. If you believe this is the case please call 877.999.5612.

What do I do if my name is spelled incorrectly or the date of birth is wrong on my Medicaid ID card?

Contact your Benefits Specialist at your local DSS office and provide him/her with the correct information. It will then be corrected in SD Medicaid’s records and you will be issued a new card. If you did not apply at a local office, please call 877.999.5612.

How do I know what services are covered by Medicaid?

Contact your medical provider or South Dakota Medicaid at 1.800.597.1603.  You can also view covered services in the Medicaid Recipient Handbook.

Are check-ups/preventative care covered by Medicaid?

Yes. South Dakota Medicaid covers check-ups/preventative care.  The type of coverage differs by program type.

  • Full coverage adults: Yearly Well-Adult check-up and screenings, dental exams and cleanings, eye exam and immunizations.
  • Children: Yearly Well-Child check-ups, dental exams and cleanings, eye exam and immunizations.
  • Pregnant women: Prenatal exams and labs.

Can I go to the Emergency Room (ER)?

You may go to the ER for a serious health problem that may cause lasting injury or death, such as severe bleeding, chest pain, shortness of breath, severe pain, severe allergic reaction or loss of consciousness.

Do not go to the ER for treatment of a cold, cough or other minor illness or injury, your doctor can treat in the office or over the phone.  You will be responsible to pay the bill for non-referred, non-emergency services.

**Acute care and urgent care clinics offer instant care for acute illnesses and minor injuries on a walk-in basis. If you are enrolled in the PCP or the health home program, call your PCP or HHP before going to an acute care or urgent care clinic. 

Does Medicaid cover dental services?

Children and adults receive different dental coverage from Medicaid. Children coverage includes two exams and two cleanings per year, most dental sealants and other services to prevent tooth decay. Cavity fillings are also covered. Crowns, root canals, dentures, partials and other services to fix problems have limits, and most must be pre-approved. Talk to the dentist before treatment to know what is covered.

Braces and other orthodontic services are covered only when medically necessary for the worst cases. The child’s teeth must be bad enough to limit the ability to eat, chew and talk. All braces must be pre-approved. A replacement retainer is covered one time.

Adult coverage includes two exams and two cleanings per year. Cavity fillings are also covered. Crowns, root canals, dentures, partials and other services to fix problems have limits, and most must be pre-approved.

There is a $1,000 limit every year (July 1 – June 30) for covered dental services. You must pay for services over the $1,000 yearly limit. The limit does not apply to medically necessary emergency services or to dentures and partials. You can ask your dentist to seek pre-approval from Delta Dental of South Dakota before you schedule your dental work. Then you will know what will be covered and what portion of the bill you might be responsible to pay. Delta Dental of South Dakota can also tell you if the $1,000 yearly limit has been or will be reached. Call Delta Dental of South Dakota at 800.627.3961 if you have questions about pre-approval, payment or the $1,000 limit.

Do I need a Primary Care Provider (PCP)?

A PCP is a provider or clinic you see for most of your medical care. Recipients eligible for the following programs must participate in the Primary Care Provider Program:

  • Supplemental Security Income (SSI) recipients: blind, disabled people age 19 and older
  • Parent and other caretaker relatives
  • Children on Medicaid or Children’s Health Insurance Program (CHIP)
  • Pregnant Women

How do I select a PCP?

If you are required to participate in the Primary Care Provider Program, you will receive a letter shortly after you are approved for South Dakota Medicaid with instructions on how to choose your PCP. Choose your PCP online with our Online Provider Selection Tool.

If you are required to participate in the Primary Care Provider Program and you do not choose a PCP, DSS will choose one for you. Contact DSS at 800.597.1603 if you have questions.

When should I make an appointment with my PCP?

DSS recommends scheduling your annual check-up or prenatal care with your new PCP so you can establish care.  If you have another illness, you should go to your PCP before seeing other providers.  Your PCP can write a referral for services they cannot provide.

Can I change my PCP?

Yes. You may change your PCP at any time online with our Online Provider Selection Tool. Your new PCP will go into effect the first day of the following month.

I forgot the name of my PCP. What do I need to do now?

Contact your Benefits Specialist at your local DSS office or call 1.800.597.1603 with your Medicaid ID number.

Do I need a referral to see a provider other than my PCP?

Yes. Most services from another provider require a referral from your PCP. You should get a referral before receiving the service. This is true even if it is a specialist, hospital service (including any non-emergency ER service), or acute/urgent care visit. View the recipient handbook for a complete list of services that require a referral and services that do not. A referral can be made by your PCP via a telephone referral, physician order, prescription, referral card, or certificate of medical necessity.

Is a paper referral card required to see a provider other than my PCP?

No. A referral card is a tool that indicates the information required by the "referred to" provider. A referral can be provided in many ways; examples include a telephone referral, a physician order, a prescription, or a certificate of medical necessity.

Will Medicaid cover out-of-state services?

Services more than 50 miles from the South Dakota border require an out-of-state prior authorization.  See Out-of-State section below for more information about out-of-state prior authorizations.

I have Medicaid. Why am I still getting a bill?

There are many reasons you may get a bill. Do NOT ignore medical bills.
Some common issues include:

  • You were not eligible for Medicaid on the date you received care.
  • The provider is not enrolled with South Dakota Medicaid.
  • You did not get a referral from your PCP if you are in the Primary Care Provider Program or Health Homes Program.
  • You did not get the service prior-authorized and the service requires a prior authorization.
  • The provider may have incorrect information and needs you to contact them in order to bill South Dakota Medicaid.
  • You did not provide your Medicaid card number.
    • Remember to provide your newborns Medicaid card number to both the hospital and the provider.

I have pregnancy only coverage.  What does Medicaid cover?

Pregnancy-only coverage only covers services related to or caused by the pregnancy. Please talk to your PCP or South Dakota Medicaid about whether a service will be covered if you are unsure. 

Routine dental and vision services are not covered in this program.  If you feel you have a health issue that may put you and your baby at risk, contact your PCP.

How do I add my newborn child to my caseload?

Please contact your Benefit Specialist at your local DSS office or call 877.999.5612.

Can I be reimbursed for travel to an appointment out of town?

The Non-Emergency Medical Travel Program reimburses travel to medical appointments outside your city of residence.  The program reimburses you for mileage and may reimburse you for meals and lodging on overnight travel over 150 miles from your city of residence.

How can I find a Medicaid dental provider?

Visit Insure Kids Now and enter the required information in their search engine. You can also call the Delta Dental Medicaid Referral Line at 800.627.3961.

My provider told me I have another type of medical insurance other than Medicaid. I DO NOT have any other insurance. What do I do?

Contact your Benefits Specialist at your local DSS office and provide him/her with the correct information. It will then be corrected in our system. If you did not apply at a local office, please call 1.800.597.1603.

If you need a prescription filled immediately, please call 800.597.1603.

Will my child be covered this summer when he/she goes to stay with his/her mother/father?

Your child will remain eligible for Medicaid provided all other eligibility factors remain the same. However, it is important to remember that if your child needs medical services out-of-state, the provider must be a SD Medicaid provider and obtain a prior authorization for out-of-state services.

In addition, if your child is in the Primary Care Provider Program, he/she will need to get a referral from his/her primary care provider.

How do I obtain a certificate of coverage for my new insurance?

Please call 877.999.5612 and ask for a certificate of coverage.

Are broken, lost, or stolen eyeglasses covered?

South Dakota Medicaid will replace eyeglasses that are broken beyond repair and are returned to the provider.  Children who have had their eyeglasses stolen or are lost, may receive a replacement pair. SD Medicaid will not cover lost or stolen eyeglasses for adults.

Does SD Medicaid pay for contact lenses?

Coverage depends on the type and reason contacts were prescribed. Please speak with your provider to learn more about coverage options.

Will my child's sports physical be covered by South Dakota Medicaid

Children ages 3 through 20 are eligible for one well-child check-up each year. A well-child check-up may be used as a sports physical.  Sports physicals not done during a well-child check-up are not covered.

What do I do if my prescription is NOT covered?

First check the Medicaid Recipient Handbook. If you are unable to determine why it was not covered you should talk to your pharmacist or doctor. If you still have questions you may call 1.800.597.1603.

Non-Emergency Medical Travel Frequently Asked Questions

What can I be reimbursed for?

The NEMT program may reimburse you for mileage, lodging and meals at the current rate of payment.

A recipient may not receive reimbursement for lodging and meals for days the recipient is an inpatient in a hospital or medical facility.

How do I know if I qualify for NEMT reimbursement?

In order for you to be reimbursed for your travel you must be on a medical assistance program that provides Medicaid travel coverage.

Travel must be to the closest medical facility or medical provider capable of providing the necessary services. The service must be a Medicaid covered service that is provided by a medical provider who is enrolled in SD Medicaid.

If I have a medical appointment within the city I live, can i get reimbursed?

No. Mileage is limited to the actual miles between two cities and does not include miles driven within the city.

Can I get reimbursed to travel to my Primary Care Provider (PCP) or health Home Provider (HHP)?

Travel to the closest PCP or HHP is reimbursable. If travel is not to the closest PCP or HHP, travel will only be reimbursed if a "good cause" exception has been approved by Medical Services. Lodging and meals are not reimbursable when travel is to a PCP or HHP.

If my PCP or HHP refers me to a medical specialty provider, do I need a copy of my referral card?

Yes. Trips to medical specialty providers other than your PCP or HHP require a referral.

What do I need to do to get travel reimbursement to and from my medical appointment?

The Medicaid Non-Emergency Medical Travel Form must be completed and signed by the recipient, parent or guardian. The Medical Provider section of the form must be completed and signed by the receptionist, nurse or medical provider.

NEMT Payment Authorization Form must also be completed to have your payments either direct deposited into your checking or savings account or onto an electronic debit card.

The form, along with any necessary documentation, may be turned in at your local Department of Social Services’ office, mailed directly to: Department of Social Services, Office of Finance/EBT, 700 Governors Drive, Pierre, SD, 57501, emailed to dss.ebtstateoffice@state.sd.us, or faxed to 605.773.8461.

If I have already completed the NEMT Payment Authorization form, do I need to complete the form again?

A new form only needs to be completed when you are notifying NEMT of a change to how you want to receive your reimbursement, or a name change and /or address change.  

If I had to stay overnight due to my medical appointment, do you need a copy of my motel receipt?

Yes. A motel receipt is required for lodging reimbursement. Lodging is reimbursable when the provider is at least 150 miles from the recipient's city of residence and travel is to obtain specialty care or treatment that result in an overnight stay.

When will I receive my reimbursement?

You will receive your reimbursement when all required forms and verifications have been received in our office and processed.  Claims are processed in the order they are received in our office.  Please allow 6-8 weeks from the date your claim was received in our office to be processed. You will receive a Paid Claims Statement showing specific travel dates and amounts in the mail once your claim has been paid.

How or where can I get the Medicaid Non-Emergency Medical Travel Form?

You can obtain the Medicaid Non-Emergency Medical Travel Form at your local Department of Social Services Office, on the DSS online Forms and Publications page or by calling 866.403.1433.

After my appointment I realized that I forgot to have the medical provider sign the reimbursement form verifying my appointment, what can I do?

Mail or fax the reimbursement form to the medical provider to complete the Medical Provider section. The medical provider can fax the completed form to our office.

Will I be reimbursed for meals for a same day medical trip?

No. Meals will be reimbursed only if an overnight stay is medically necessary and the overnight meets the lodging requirement criteria.

Can I get reimbursed to travel to medical appointments out-of-state?

Medicaid covered services received more than 50 miles outside of the state of South Dakota, except Bismarck, ND, will require prior authorization. This applies to all Medicaid recipients, including those not in the PCP or HHP program.

If your doctor recommends you see a doctor out-of-state, please ask your doctor if prior authorization is needed before you make the appointment. If approval is not given, you will be responsible for the medical bill and travel costs.

Prior authorization must be approved before travel expenses can be approved or paid.

NOTE: If you are in the PCP or HHP program and traveling to Bismarck, ND, a referral from your PCP or HHP is still required. If you are not in the PCP or HHP program, travel will only be reimbursed if Bismarck, ND, is the closest provider capable of providing the services.

Can lodging be paid by NEMT if one parent/guardian/escort stays in the hospital and the other parent/guardian/escort stays in a hotel room?

No. NEMT will only reimburse for the recipient and one parent/guardian/escort at the least costly method to the State.

I have a hotel room booked and I do not want to lose my room but have to return home over the weekend. Can I keep my belongings in the room and still be reimbursed by NEMT?

No. NEMT can only reimburse for nights the recipient and/or escort are present in the lodging establishment.

Provider Frequently Asked Questions

How do I know which services require a prior authorization?

All services requiring a prior authorization and the associated Prior Authorization Request forms can be found on our Prior Authorization page along with the Prior Authorization Manual

What if I am not an enrolled South Dakota Medicaid provider?

Out-of- state providers who are not enrolled as a South Dakota Medicaid provider must follow the process to obtain prior authorization beginning with the submission of a Prior Authorization Request Form. If the request is approved, the provider will receive written notification stating the determination was made pending enrollment.  Once the approved service(s) have been provided, the provider must complete the online enrollment application with South Dakota and submit the resulting claim and the written prior authorization approval notification with the Provider Enrollment documentation.

Please note that Administrative Rule of South Dakota §67:16:35:04 requires claims to be filed within 6 months of the date of service.

Where can I find a paper enrollment application?

South Dakota Medicaid does not have a paper application.  Applications can be started online. If there are extenuating circumstances regarding online submission, please contact DSS at 605.773.3495

How long does it take to process new applications or updates to my record?

Applications and modifications are generally processed in the order in which they are submitted and response time can vary depending on the volume of other applications and modifications and the time of submission.

Do I have to enroll individual providers?

If a provider’s NPI is required to be included as a servicing or rendering provider on a CMS 1500 claim form or equivalent 837P claim loop/segment as captured in the billing manuals, the provider must be enrolled.

NPIs belonging to individuals that are listed only as attending, referring, or operating providers that are not billed by an IHS facility generally do not have the complete an enrollment application.  South Dakota will use its streamlined enrollment process during the claim adjudication process to ensure the listed attending, referring, or operating individual is meets the requirements to be deemed enrolled for claim processing.  These requirements include items such as being a type of provider eligible to enroll, active license in good standing for location of rendered services, not deceased on date of service.

How long does my enrollment last?

Enrolled providers who have not had paid claims within a 24 month period may be terminated for inactivity. Providers are required to maintain their record as changes occur and also complete revalidation in accordance to federal requirements upon South Dakota Medicaid notice. The revalidation process is anticipated to occur every 3-5 years.

How can providers receive Remittance Advices (RA's)?

Providers may access their remittance advices via the Provider Online Portal.  The Provider Online Portal gives the provider the ability to view and download copies of Remittance Advices.  To log onto the Provider Online Portal click here. For more information about how to access the portal please click here. For assistance and questions regarding the Portal providers may send an email to DSSonlineportal@state.sd.us or call 605.773.3495.

Where do I find an excluded provider list?

South Dakota Medicaid excluded providers can be found on the U.S. Department of Health & Human Services Office of Inspector General’s Exclusions Database.

Health Homes

What is a Health Home?

South Dakota’s health home program offers enhanced health care services to Medicaid recipients with chronic conditions like asthma, COPD, diabetes, heart disease, hypertension, obesity, substance use disorder, mental health conditions, pre-diabetes, tobacco use, cancer, hypercholesterolemia, depression, and musculoskeletal and neck/back disorders.

The full definition of core services can be found by clicking here.

Health Homes are encouraged to utilize health information technology to more efficiently and effectively coordinate the care of Health Home patients.

Through the provision of the six core services, the Health Home initiative aims to reduce inpatient hospitalization and emergency room visits, increase the integration between physical and behavioral health services and enhance transitional care between institutions and the community.

Why did South Dakota implement Health Homes?

South Dakota implemented Health Homes to improve health outcomes and experience of care for eligible Medicaid recipients, while also realizing cost savings from better coordinated care for that population. See how this program has gained efficiencies and improved health outcomes by viewing our data dashboard.

Who is eligible for Health Homes?

South Dakota has two types of Health Homes -- those led by Primary Care Providers and those led by a Community Mental Health Centers -- to serve Medicaid recipients with complex health care needs resulting in high costs to Medicaid. Individuals who are eligible for these two health homes include:

  1. Medicaid recipients with two or more chronic conditions or recipients with one chronic condition who are at risk for a second chronic condition.

    A. Chronic conditions include: Mental Health Condition, Substance Use Disorder Asthma, COPD, Diabetes, Heart Disease, Hypertension, Obesity, Musculoskeletal and Neck/Back disorders.

    B. At-risk conditions include: Pre-Diabetes, tobacco use, Cancer, Hypercholesterolemia, Depression, and use of multiple medications (6 or more classes of drugs).

  2. Recipients who have a Severe Mental Illness or Emotional Disturbance

What do providers need to do to become a Health Home Provider?

Providers who would like to serve as a designated provider and feel they meet the required provider standards should complete an application.

 Click here to view the Health Home application training. Questions on the application can be directed to the number on the webpage. The Department of Social Services will review completed applications to ensure each provider meets the standards. After the application is approved, onsite training will be provided to each Health Home.

Who provides Health Home Services?

Each Health Home is led by one or more designated providers.  Each designated provider leads an individualized team of health care professionals and support staff to meet the needs of each recipient.  A designated provider team may include a health coach/care coordinator/care manager, chiropractor, pharmacist, support staff and other services as appropriate and available.

Designated providers for Health Homes include providers licensed by the State of South Dakota who practice as a primary care physician, (e.g., family practice, internal medicine, pediatrician or OB/GYN), physician’s assistant, advanced practice nurse practitioner, Federally Qualified Health center, Rural Health Clinic, Indian Health Service, clinic group practice; or a mental health professional working in a Community Mental Health Center. 

Where are Health Homes located?

Health Homes are located where there are qualified designated providers are willing to serve the needs of those eligible. You may choose your HH online with our Online Provider Selection Tool.

How are providers reimbursed for Health Home Services?

Medical Services are funded exactly as they are now. The Health Home provider will be paid a per-member per-month (PMPM) payment based on the tier of the recipients to cover the cost of providing the 6 core services required by Health Homes.

Prior Authorization

Only one prior authorization is needed for the hospital stay. Physician services are included as part of the prior authorization for the inpatient stay. A prior authorization will be issued to the prior authorization contact for the inpatient facility for the dates of the approved hospital stay. In addition to the hospital facility, this authorization must be shared with all physicians to use for visits billed during that hospital stay.

Inpatient Hospitalization 6-Day Notification Form Frequently Asked Questions

Which hospitals are required to submit day six notification forms?

All in‐state hospitals, hospitals within 50 miles of the South Dakota border, and hospitals in Bismarck, ND must submit the form for Medicaid recipients on day six of an acute inpatient hospital admission.

Is the notification form required for inpatient cases where South Dakota Medicaid is the secondary or tertiary payer?

Yes.

Is notification required for all Medicaid programs regardless of the type of Medicaid assistance that recipient is receiving, i.e. QMB, Home Care Waiver, SSI Medicaid, Long Term Care, Assisted Living Waiver, CHIP?

Yes, but this notification process applies only to acute inpatient hospital stays.

Is the notification form required for inpatient hospital stays involving patients with pending South Dakota Medicaid applications (including inmates)?

No. The form must be submitted at the point Medicaid eligibility is approved if the stay is at day six or beyond.

Do we need to report inpatient hospitalizations if Medicaid eligibility determination is made retro‐actively?

Only if the recipient is still an inpatient when the eligibility is approved and the stay is at day six or beyond. Notice does not need to be provided for retro‐active stays if the patient has already been discharged.

Why are hospitals being required to submit notification for extended acute inpatient stays?

This requirement is consistent with other insurers and is intended to assist DSS in identifying opportunities to improve efficiency within South Dakota Medicaid.

How will this length of stay information be used? When will hospitals receive calls from a DSS nurse?

This information will be utilized to increase efficiencies in South Dakota Medicaid. DSS nurses focus on projected stays of extended hospitalizations, situations that are not consistent with standard length of stay per diagnosis, and providing assistance to hospitals to develop strategies for timely and appropriate care transitions.

Where is the form located? How do I submit the form?

The inpatient reporting form is located on our website; click on the fill out the form link. The form must be submitted directly online.

If I submit the form online will that form be available to submit the discharge date or will I have to resubmit a new form?

Yes. When you login, click on the option to Add discharge information. Then click on the dropdown box beside Confirmation No. to find the original admission form to update it.

Does the day of admission count towards the six days for reporting purposes?

No. For example, if a recipient is admitted on the first of the month, the notification form should be submitted on the seventh.

If the notification form is submitted online on day seven or later, will the inpatient hospital claim be denied? Will appeals be considered?

The form must be submitted during day 6 of the admission. At this time, the notification process is not tied to claim adjudication as we anticipate that South Dakota Medicaid providers will comply with this process.

Will I receive a confirmation number after I electronically submit the form so I know it was received?

Yes, you will receive a confirmation number for tracking purposes. The confirmation number will allow you to add discharge information.

When is the discharge form required to be submitted?

The discharge notification form is required at the time of discharge unless it is after 5 pm, in which case the form may be submitted the following business day by noon.

Will the program be staffed on weekends and holidays? Is this something that can wait until Monday or after the holiday for both the initial reporting and the discharge forms?

Both the initial notification and the discharge forms may be submitted by noon the following business day.

Do observations days (OBV) count toward the six inpatient days?

Yes.

If the inpatient stay is for a DRG‐exempt unit (Neo‐natal intensive care unit, rehabilitation, and psychiatric) unit, do I have to report the stay?

No, DSS has already been notified and will complete this form for the provider.

Please click on the Contact Us tab at the top of the page and provide either a link or description of the page where you are encountering problems.