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Frequently Asked Questions

What is the South Dakota Medical Assistance Program (SDMA)?

Medical Assistance is a state and federally funded program providing medical coverage for individuals who meet certain eligibility guidelines. If you are eligible, Medical Assistance acts as your insurance company and pays for the cost of medically necessary services such as visits to the doctor, hospital, dentist, specialist, etc. These services are subject to cost-sharing by the enrolled individuals and are authorized and limited by South Dakota Administrative Rule.

Do I qualify for Medical Assistance?

Whether or not you qualify, depends on your income and circumstances. For more information, visit Medical Eligibility or your local office.

More Questions?

If you have questions about covered services, contact your medical provider or the South Dakota Medical Assistance Program at 1-800-597-1603. You can also send an email to Medical@state.sd.us.

Recipient FAQ

How will SD MEDX assist Medicaid recipients?

SD MEDX provides up-to-date information about recipient eligibility and claims, as well as current physicians and other medical providers in an online directory that recipients can access.

How do I choose a Medicaid provider?

Before seeing a provider, you will need to confirm the provider is a South Dakota Medicaid provider. When making the first contact with the provider by phone, simply ask if they accept South Dakota Medicaid. If they do, you can schedule an appointment.

Do I need a Primary Care Provider (PCP)? If so, how do I select one?

If you are required to participate in the Managed Care Program, the Department of Social Services will notify you in writing that you need to choose a Primary Care Provider (PCP). A PCP is a physician or clinic who you see for most of your medical care.

DSS will give you a selection form and a list of PCPs in your area. You need to complete the form by choosing a PCP for each eligible member of your family. View a list of PCPs on the SD MEDX Portal via the Provider Locator.

If you are required to participate in Managed Care and you do not choose a PCP, DSS will choose one for you. Contact us at 1-800-597-1603 if you have questions. Save time by selecting your PCP online.

Your chosen or assigned PCP becomes effective the first day of the month after you select or are assigned a PCP. DSS will notify you with the name of your PCP and the date your enrollment begins. You must receive most of your medical care from your PCP in order to have Medicaid assist with paying for it. However, your PCP may refer you to other providers when appropriate.

Please consider the following when choosing a PCP for you and your family:

  • Type of provider:
    • Pediatricians usually serve only children.
    • OB/GYN providers only serve women and usually for just pregnancy and gynecology services.
    • Internal Medicine doctors usually serve only adults.

  • Location:
    • Consider how far you must travel to visit your PCP.
    • SDMA will only assist with reimbursement to the closest provide

  • Provider's Existing Caseload:
    • Some providers have full caseloads and will not accept new patients. This is indicated by an asterisk or "*" next to the PCP's name.
    • DO NOT select a PCP with a full caseload unless you are sure you will be accepted.
    • Check with the PCP's office before you make the selection.

  • Special needs:
    • If you or an eligible family member has special health care needs, contact the PCP's office before making your selection to ensure the provider will meet your needs.

Can I change my Primary Care Provider?

You can change your PCP in several different ways:

Can I see a provider other than my PCP?

If you are in Managed Care, a referral is required from your PCP or designated covering provider prior to receiving services from another provider, even if it is a specialist or a hospital service (including any non-emergent ER service), acute/urgent care visits or other designated services. View the recipient handbook for more services that would require a referral. A referral can be made by your PCP via telephone referral, physician order, prescription, referral card, or certificate of medical necessity.

Is a Referral Card physically required for Managed Care recipients?

No. A proper referral can be provided in many ways, i.e. a telephone referral, a physician order, a prescription, a certificate of medical necessity, etc. As long as the referral mechanism used provides the "referred to" medical provider with the Managed Care necessary information to process the claim as indicated on a referral card (PCP name and #, length of referral, type of service to be provided, date, recipient name).

The referral card is simply a tool indicating the required information needed by the "referred to" provider.

I forgot the name of my child's 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 child's Medicaid ID number. In the future, you will be able to access this information by logging into SD MEDX.

Can I go to the Emergency Room?

When you have a serious health problem that could cause lasting injury or death, you can receive care at the emergency room (ER) and Medicaid will assist with payment.

Examples requiring ER care:

  • Severe bleeding
  • Severe shortness of breath
  • Severe pain
  • Severe allergic reaction
  • Broken bones
  • Chest pain
  • Loss of consciousness

If a medical problem arises that may not be an emergency and you are not sure what to do, call your PCP or on-call provider if it is after hours. If the PCP or on-call provider contacts the ER and refers you prior to a non-emergent service, Medicaid will assist with the payment of these services.

If you go to the ER for a non-referred, non-emergent service, you will be responsible for payment of these services.

I took my child to the ER due to my PCP being closed; it was midnight on a Saturday. I am now being billed by the hospital for not providing a referral. I thought ER visits were covered by Medicaid?

If you did not obtain a prior referral to go to your PCP and the visit is not determined to be an emergency by ER staff, you may be billed for the services. Only emergent visits to the ER are covered by South Dakota Medicaid without a PCP referral.

I've been told I have Medicaid, why am I still getting a bill?

There are many reasons you may be receiving a bill. Some common issues include:

  • You were not eligible for Medicaid on the date you went in to receive care.
  • The provider is not enrolled with the South Dakota Medical Assistance Program.
  • You did not get a referral card from your PCP if you are in the managed care program.
  • You did not get the service prior-authorized if it required to do so.

Does the South Dakota Medical Assistance Program cover dental services?

You may be eligible for dental benefits under your South Dakota Medical Assistance coverage. South Dakota Medical Assistance includes many dental services for adults and children. If you are 21 or older, dental services that are not emergency services are limited to a total of $1,000 for the State fiscal year, July 1 to June 30.

Covered Preventive/Restorative Treatments include:

  • Examinations
  • X-rays
  • Fluoride Varnishes
  • Extractions
  • Fillings
  • Root canals
  • Dentures

South Dakota Medical Services does NOT cover orthodontics for adults. Orthodontic treatment is a benefit only for children in limited, medically-necessary circumstances.

How can I find a Medicaid dental provider?

Visit Insure Kids Now and click on the Medicaid link under South Dakota.

You can also call the Delta Dental Medicaid Referral Line at 1-800-627-3961.

Why am I receiving medical claims for my hospital stay when I am on South Dakota Medical Assistance?

It is possible that your provider does not know you are eligible for medical assistance. Please be sure to provide your provider with your Medical ID card each time you receive a service. If you contact your provider and they inform you that your Medical Assistance has ended, please contact your local DSS office to inquire about possible eligibility.

I am being told my child has another type of medical insurance other than Medicaid. My child DOES 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 to our system and you will be issued a new card. If you did not apply at a local office, please call 1-877-999-5612.

We were visiting family in another state and had to fill a prescription for our child through a non-South Dakota Medical Assistance (SDMA) provider. How do I get reimbursed for the prescription?

The pharmacy where you purchased the prescription will need to enroll with SDMA, then submit the claim to SDMA and finally reimburse you. SDMA cannot directly reimburse recipients.

My child broke his glasses for the second time in the past 15 months. The eye doctor is telling me SDMA will not cover another pair. How is my child supposed to see without glasses?

SDMA will replace eyeglasses that are broken beyond repair and are returned to the provider.

What do I do if my child's Medical Assistance card has an incorrect spelling or date on it?

Contact your Benefits Specialist at your local DSS office and provide him/her with the correct information. It will then be corrected in to our system and you will be issued a new card. If you did not apply at a local office, please call 1-877-999-5612.

I was in a car accident in another state and had to be airlifted to a hospital. I am now receiving a bill. Why is this claim being denied?

The provider may not be a SDMA provider. In this case, the provider will need to enroll with SDMA as a provider so they can submit the claim for payment. Call our Department at 1-800-597-1603 so SDMA can work with the facility to get them enrolled.

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 medical services. Why is this happening?

In South Dakota individuals who receive a Supplement Security Income (SSI) payment are automatically eligible for Medical Assistance. If your child is no longer receiving a payment his/her eligibility would end. The Social Security Administration determines the eligibility for payments.

When this happens you will receive a notice from our Department 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 our office has not yet been notified. If you believe this is the case please call 1-877-999-5612.

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

Please call 1-877-999-5612 and ask for a certificate of coverage.

Does the South Dakota Medical Assistance Program cover the lap band procedure?

Requests for the lap band or other bariatric surgeries can be submitted for prior authorization consideration. Documentation must include conservative weight loss efforts, co-morbidities, psychiatric evaluation, along with a surgical evaluation.

Does SDMA 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 Medical Assistance?

Children ages 3 through 20 are entitled to one comprehensive well child exam each year. Sports physicals, completed through this exam, are covered.

How do I add me newborn child to my caseload?

Please contact your Benefit Specialist at your local DSS office.

What do I do if I lost my Medical Assistance ID card?

Please contact your Benefits Specialist at your local DSS office or call 1-877-999-5612.

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

Your child will remain eligible for medical assistance provided all other eligibility factors remain the same. However, it is important that if your child needs medical services out of state, he/she will need to go to a provider who accepts South Dakota Medical Assistance.

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

What do I do if my prescription is NOT covered?

Please review the prescription drug administrative rules for specific information on what is and is not covered. Your Medical Assistance Recipient Handbook also provides this information. If you still have questions, call us
at 1-800-597-1603.

Provider FAQ

PROVIDER ENROLLMENT

How will provider enrollment change?

Providers will soon be able to complete their enrollment through SD MEDX. Required attachments can be uploaded, mailed or faxed to a secure, central location for scanning and entry into SD MEDX. Learn more.

As an enrolled provider, will I need to change how I submit information updates to the SDMA enrollment staff?

Providers will be able to update contact information, address information, office hours and more via SD MEDX.

SD MEDX

What will providers be able to do with this new system?

Providers will be able to submit claims, prior authorization requests, and eligibility inquiries. In turn, they will get immediate response about the status of those requests; all while doing it online.

Is SD MEDX secure? How will providers get access to SD MEDX?

Yes, SD MEDX is secure. It is only available to enrolled providers in the South Dakota Medical Assistance Program. Users must have a secure username and password to access SD MEDX; which comes directly from the South Dakota Medical Assistance Program. Log in credentials are sent to authorized providers via U.S. ground mail. Providers can then log in to SD MEDX.

Can providers see a demonstration of SD MEDX?

Yes. All training opportunities are available here.

How far back will providers be able to access historical claims on SD MEDX?

All claims on file in SD MEDX will be available to providers; this includes 6 years of converted historical claims.

Do providers have to do any testing in order to use SD MEDX?

No testing is required to use SD MEDX. All providers need is a computer with an Internet connection that supports Internet Explorer 6 or 7, Mozilla Firefox 3.0.8, or Safari 4.0. They will also need their secure log in credentials.

TRAINING

Provider Training

What kind of training is available?

All training opportunities are available here.

Who will train new providers on the SD MEDX?

The SD MEDX Response Team will be training providers on the new system. Providers will receive more details as we approach the enrollment process.

I won't be able to attend SD MEDX training in my area. Can I go to another town?

You can go to any of the statewide trainings. Providers are required to register for training sessions online. If you are unable to attend a live training session, there are online options available as well. Review the training opportunities.

Other

Are provider payments through electronic transfer only?

South Dakota Medical Assistance requires all providers to use electronic funds transfer (EFT) as their payment method.

How will we receive Remittance Advices (RA's) in SD MEDX?

You will still have the same options for receiving these messages:

  • Paper RA's
  • Electronic 835 transaction

Additionally, providers will be able to access their RAs online.

Login FAQ

What are the system requirements to use SD MEDX?

To use SD MEDX, you will need a compatible browser and an internet connection. If you have support staff who do not have internet access and you want them to perform certain functions within SD MEDX, make sure you provide that person with the appropriate log in creditials provided by our Department.

System requirements include:

  • Office 2007
  • Adobe Acrobat Reader 8
  • Internet Explorer 6.0 or 7.0, Mozilla Firefox 3.0.8, or Safari 4.0

Is SD MEDX compatible with both Macs and PC's?

Yes.

Do the SD MEDX passwords expire?

SD MEDX passwords expire every 90 days.

How do I search within SD MEDX?

To search SD MEDX, please enter the desired subject matter in the search box on the top right hand side of each tab on the portal. Then click on the most appropriate link based on what you are looking for.

What do I do if I encounter page errors in SD MEDX?

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 encountering problems. Please also explain what happened so our staff are better able to correct the error.