Cabinet Secretary
Matt Althoff

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All Prior Authorization requests and inquiries need to be emailed to DSSMedicaidPA@state.sd.us until further notice

Prior Authorization

The division has 30 days to make a prior authorization determination. However, in most circumstances authorizations can be completed in less time, usually around 2 weeks. Prior authorization is only required for the elective services listed on this webpage. Any urgent or emergent care is exempt from prior authorization requirements. Retro authorizations can be requested after the service is provided if care was suspected to be urgent/emergent at the time, but will be billed as elective.

Listed below are all services requiring prior authorization and the associated Prior Authorization Request Form. Prior Authorization criteria and detailed instructions regarding forms and submission of prior authorization requests are located in the Prior Authorization Manual.

Durable Medical Equipment

Bone Growth Stimulators

Continuous Glucose Monitoring

Continuous Passive Motion Devices

Cough Stimulating Devices

Cranial Remolding Helmets

High-Frequency Chest Wall Oscillation Device

Low Air Loss Mattress / Pressure Reduction Therapy

Lymphedema pumps

Non-covered items < age 21 (EPSDT)

Specialty Mobility Devices

Speech Generating Devices / Augmentative Communication Devices

Wound Vacs

Incontinence Supplies

Durable Medical Equipment | Prior Authorization Request Form

Home Health

Extended Home Health Services / Private Duty Nursing

Private Duty Nursing & Extended Home Health Services | Prior Authorization Request Form

Inpatient Hospitalization

Long Term Acute Care | Prior Authorization Request Form

Medically Complex / Rehab < age 21

Neonatal Intensive Care Units

Psychiatric Residential Treatment Facilities

Psychiatric Units

Rehabilitation Units

General | Prior Authorization Request Form

Nutrition

Enteral Nutrition for > age 21

EPSDT special requests < age 21

Parenteral

Nutrition | Prior Authorization Request Form

Out-of-State Services

Requests for elective out of state services should be generated by the referring in state physician/specialist at the time of that referral. Medical records form the visit that prompted the referral should accompany the prior authorization request form. Requests from the out of state provider will also be accepted. However, this is only preferred when a recipient’s care has already been established there. Requests from out of state providers should be accompanied by records of their most recent services there. Authorization requests should also include a schedule of planned care throughout the next year if more than one service is anticipated. This will decrease the number and frequency of authorizations needed.

Inpatient Services

Outpatient Services

Out-of-State | Prior Authorization Request Form

Not all services provided out-of-state require a prior authorization. Please refer to the Out-of-State Providers manual for more information on services requiring prior authorization out of state..

Other Outpatient Services

Applied Behavior Analysis (ABA) Therapy Services | Prior Authorization Request Form

Botox

BRCA | Prior Authorization Request Form

Genetic Testing | Prior Authorization Request Form

Hyperbaric Oxygen Treatment

Magnetoencepalography (MEG) and Magnetic Source Imaging (MSI)

Makena

Mental Health visits < age 2

Mental Health visits over coverage limit

Non-covered services < age 21 EPSDT (Vision, audiology, etc.)

Spinraza/Nusinersen

Synagis | Prior Authorization Form

General | Prior Authorization Request Form

Other Procedures

These procedures do not require prior authorization, but they do have specific requirements including a specialized form.

Hysterectomy

Sterilization

South Dakota Medicaid In-Patient Hospitalization Form

Hospitals are required to inform South Dakota Medicaid when a recipient has been hospitalized for an acute care admission for six consecutive days.

    • The notice must be completed on day six of the acute care admission.
    • Beginning May 19th, 2023 this form will be available on the Medicaid Portal. Click on the Clinical Reviews tab and select 6 day stay reporting to access the +Add 6 Day Form button. The previous method for hospitals to enter 6-day notification forms will cease being available to providers on June 2, 2023.
    • For more information and instructions, please see the 6 Day Reporting Guide
    • Upon discharge, please submit the form with the pertinent discharge information.

Physician Administered Drugs, Vaccines and Immunizations

Drugs, vaccines and immunizations that are administered to a patient as part of a clinic or other outpatient visit are not covered under the pharmacy benefit and are to be billed to Medicaid directly. For a list of the physician administered products that require a prior authorization, please see the Physician Administered Drugs, Vaccines and Immunizations Page.

Surgical Procedures

Bariatric

Breast Reconstruction

Breast Reduction

Cochlear implants

Nerve stimulators

Panniclectomy

Questionably cosmetic

Removal of excess skin

Spinal

Transplants

General | Prior Authorization Request Form

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