1 67:16:01:08. Services not covered. In addition to items and services specified as not
covered in other sections of this article, the following items and services are not covered
under the medical assistance program:
(1) Items or services which have been determined by the state dental or medical
consultant or through peer reviews to be not medically necessary, safe, or effective;
(2) Items or services for which the recipient has no legal obligation to pay or which
are charges imposed by immediate relatives or members of the recipient's household;
(3) Over-the-counter drugs, home remedies, food supplements, nutritional items,
vitamins, or alcoholic beverages, except as covered under chapter 67:16:14 or 67:16:42;
(4) Diagnosis or treatment given in the absence of the patient;
(5) Cosmetic or reconstructive surgery to improve the appearance of an individual, if
not incidental to prompt repair following an accidental injury or any cosmetic or
reconstructive surgery that goes beyond that which is necessary to improve the functioning of
a malformed body member except reconstruction after a medically necessary mastectomy or
if incidental to prompt repair following an accidental injury;
(6) Items or services provided by practitioners or agencies in the employ of or under
contract with the federal, state, or local government, except state:
(a) State institutions for the developmentally disabled that are certified as
skilled nursing or intermediate care facilities, the;
(b) The state psychiatric hospital, the;
(c) The public health service,; or the
(d) The national health service;
(7) Organ transplants, except as authorized under chapter 67:16:31;
2 (8) Acupuncture;
(9) Biofeedback;
(10) Chronic pain rehabilitation program services or chronic pain management
services, except as allowed under chapter 67:16:14;
(11) Alcohol and drug rehabilitation therapy, except for services provided under
chapter 67:16:48;
(12) Procedures for implanting an embryo;
(13) Gastric bypass, gastric stapling, gastroplasty, any similar surgical procedure, or
the associated conservative weight loss management unless prior authorized;
(14) Self-help devices, exercise equipment, protective outerwear, personal comfort
services or environmental control equipment, such as air conditioners, humidifiers,
dehumidifiers, heaters, or furnaces;
(15) Medical equipment for a resident in a health care facility, except as authorized
under chapter 67:44:03;
(16) Autopsies;
(17) Custodial care, except as authorized under chapter 67:44:03;
(18) Nursing facility services for individuals age 21 twenty-one and over and under
age 65 sixty-five in institutions for mental disease;
(19) Broken appointments;
(20) Reports required solely for insurance or legal purposes unless requested by the
department, the Department of Health, or the Department of Human Services;
(21) Concurrent care by more than one provider of the same discipline for the same
diagnosis without a medical referral detailing the medical necessity of the concurrent care.
3 For concurrent care without medical referral, the department will pay only the first claim
submitted;
(22) A health service that is not documented in the recipient's medical record as
required by chapter 67:16:34;
(23) Vocational training, educational activities, teaching, or counseling, except
outpatient diabetes self-management education programs covered under chapter 67:16:46;
(24) Record keeping, charting, or documentation related to providing a covered
service, unless specifically allowed in this article;
(25) Payment of mileage unless specifically covered under this article;
(26) Drugs and biologicals, which the federal government has determined to be less
than effective, as listed in § 67:16:14:05;
(27) Services, procedures, or drugs, which are considered experimental by the United
States Department of Health and Human Services or another federal agency, not including
services, procedures, or drugs approved by the Food and Drug Administration under an
emergency use authorization that are being utilized in accordance with the emergency use
authorization;
(28) Procedures and services to reverse sterilization;
(29) Computers, computer hookups, or computer printers, unless prior authorized;
(30) Gambling addiction services or therapy; and
(31) Penile implants.
Source: SL 1975, ch 16, § 1; 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7
SDR 89, effective July 1, 1981; 9 SDR 11, effective August 1, 1982; 9 SDR 164, effective
4 June 30, 1983; 10 SDR 79, effective February 1, 1984; 11 SDR 26, effective August 21,
1984; 11 SDR 86, effective December 30, 1984; 15 SDR 204, effective July 6, 1989; 17 SDR
4, effective July 16, 1990; 17 SDR 184, effective June 6, 1991; 17 SDR 194, effective June
24, 1991; 18 SDR 98, effective December 9, 1991; 19 SDR 26, effective August 23, 1992; 19
SDR 165, effective May 3, 1993; 20 SDR 144, effective March 10, 1994; 22 SDR 32,
effective September 11, 1995; 28 SDR 166, effective June 12, 2002; 35 SDR 88, effective
October 23, 2008; 40 SDR 122, effective January 7, 2014; 43 SDR 80, effective December 5,
2016; 46 SDR 50, effective October 10, 2019; 47 SDR 129, effective June 3, 2021.
General Authority: SDCL 28-6-1(1)(2).
Law Implemented: SDCL 28-6-1.
Cross-Reference: Covered services must be medically necessary, § 67:16:01:06.02.
5 67:16:25:06.02. Reimbursable services -- Community transportation provider. If
the requirements of § 67:16:25:06.01 are met, reimbursable community transportation
services are limited to the following:
(1) Transport of a recipient, and an accompanying adult if medically necessary due to
the recipient’s age or medical condition; and
(2) Mileage.
Transportation expenses payable by a third party are not eligible for reimbursement
under this chapter.
Source: 20 SDR 126, effective February 10, 1994; 26 SDR 157, effective June 7,
2000; 35 SDR 253, effective May 12, 2009.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross-Reference: Covered services must be medically necessary, § 67:16:01:06.02.
6 67:16:26:05. Provider must collect from third-party source before submitting
claim to department -- Medical assistance program payer of last resort -- Payment
provision. Because the medical assistance program is the payer of last resort, a provider must
pursue the availability of third-party payment sources whether or not the sources are
identified by the department.
The provider must be able to document the provider's pursuit of the availability of a
third-party payment source, except for claims listed in § 67:16:26:07.02. The documentation
must be maintained in the recipient's records. Documentation may include a signed statement
by the recipient informing the provider of all third-party payment sources.
Once the provider has identified a third-party payment source, the provider must
submit a completed claim for payment of services to the third-party source before requesting
payment from the department. Except for an electronic claim, if a claim is subsequently
submitted to the department for payment, evidence of third-party payment or rejection must
accompany the claim. For an electronic claim, the provider must maintain and submit to the
department, on request, evidence of the third-party payment or rejection. The provider is
eligible to receive the recipient's third party liability responsibility payment from the medical
assistance program up to the amount or the amount allowed under the department's payment
schedule less the third-party liability amount, whichever is less.
The department may not pay for any service that has been denied by the third-party
liability source as not meeting the requirements for submitting a claim.
Source: 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7 SDR 89, effective
July 1, 1981; 16 SDR 226, effective June 24, 1990; 17 SDR 194, effective June 24, 1991; 26
7 SDR 168, effective July 1, 2000; 31 SDR 214, effective July 6, 2005; 40 SDR 122, effective
January 7, 2014.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross-References:
Department determination of possible existence of third-party source -- Claim denial,
§ 67:16:26:07.
Certain claims eligible for payment before third-party benefits recovered --
Department to pursue reimbursement, § 67:16:26:07.02.
Department determination of possible existence of third-party source -- Claim denial,
§ 67:16:26:07.
Records, ch 67:16:34.
8 67:16:41:01. Definitions. As used in this chapter:
(1) "Certified social worker - private, independent practice" means an individual
certified under SDCL 36-26-17;
(2) "Certified social worker - private, independent practice candidate" means an
individual who is licensed as a certified social worker under SDCL 36-26-14 and is working
toward becoming a certified social worker - private, independent practice under an approved
supervision agreement, as required by § 20:59:05:05;
(3) "Clinical nurse specialist" means an individual who is licensed under SDCL 36-
9-85 to perform the functions contained in SDCL 36-9-87;
(4) "Collateral contact" means telephone or face-to-face contact with an individual,
other than the recipient receiving treatment, to plan appropriate treatment, to assist others in
responding therapeutically regarding the recipient's difficulty or illness, or to link the
recipient, family, or both, to other necessary and therapeutic community support;
(5) "Diagnostic assessment" means a written comprehensive evaluation of symptoms
that indicate a diagnosis of a mental disorder and which meet the requirements of
§ 67:16:41:04;
(6) "Family" means a unit of two or more persons, related by blood or by past or
present marriage. A family may also include other individuals living in the same household
with the recipient, individuals who will reside in the home in the future, or individuals who
reside elsewhere, if the individual's participation is necessary to accomplish treatment plan
goals, and the individual is considered an essential and integral part of the family unit
identified in the treatment plan;
9 (7) "Group" means a unit of at least two, but no more than ten, individuals who,
because of the commonality and the nature of their diagnoses, can derive mutual benefit from
psychotherapy and the therapy can be demonstrated to be medically necessary for the
individuals to jointly participate, in order to accomplish treatment plan goals through a group
psychotherapy session;
(8) "Licensed professional counselor - mental health" means an individual certified
under SDCL 36-32-65 to 36-32-67, inclusive;
(9) "Licensed professional counselor working toward a mental health designation"
means an individual who is licensed as a licensed professional counselor under SDCL 36-32-
64 and is working toward a mental health designation under the supervision required by
SDCL subdivision 36-32-65(4) 36-32-65(5);
(10) "Licensed marriage and family therapist" means an individual licensed under
SDCL 36-33-43 to 36-33-45, inclusive;
(11) "Licensed marriage and family therapist working toward a mental health
designation" means an individual who is a licensed marriage and family therapist under
SDCL 36-33-43 and is working toward a mental health designation under the supervision
required by SDCL subdivision 36-33-43(3);
(12) "Mental disorder" means an organic disorder of the brain or a clinically
significant disorder of thought, mood, perception, orientation, or behavior;
(12)(13) "Mental health services" means nonresidential psychiatric or psychological
diagnostic and treatment that is goal-oriented and designed for the care and treatment of an
individual having a primary diagnosis of a mental disorder;
10 (13)(14) "Mental health treatment" means goal-oriented therapy designed for the care
and treatment of an individual having a primary diagnosis of a mental disorder;
(14)(15) "Psychologist" means, for services provided in South Dakota, a person
licensed under SDCL 36-27A-12 or 36-27A-13; for services provided in another state, a
person licensed as a psychologist in the state where the services are provided. For purposes
of the medical assistance program, a person practicing under SDCL 36-27A-11 is specifically
excluded from this definition;
(15)(16) "Psychotherapy" means the face-to-face or telehealth treatment of a
recipient, through a psychological or psychiatric method. The treatment is a planned,
structured program based on a primary diagnosis of mental disorder and is directed to
influence and produce a response for a mental disorder and to accomplish measurable goals
and objectives specified in the recipient's individual treatment plan;
(16)(17) "Psychotherapy session" means a planned and structured face-to-face or
telehealth treatment episode between a mental health provider and one or more recipients;
(17)(18) "Telehealth" means a method of delivering services, including interactive
audio-visual or audio-only technology, in accordance with SDCL chapter 34-52; and
(18)(19) "Treatment plan" means a written, individual, and comprehensive plan that
is based on the information and outcome of the recipient's diagnostic assessment and which
is designed to improve the recipient's mental disorder.
Source: 22 SDR 6, effective July 26, 1995; 26 SDR 168, effective July 1, 2000; 37
SDR 53, effective September 23, 2010; 45 SDR 82, effective December 10, 2018; 48 SDR
39, effective October 3, 2021.
11 General Authority: SDCL 28-6-1(1)(2)(4).
Law Implemented: SDCL 28-6-1.
12 67:16:41:03. Mental health provider. A mental health provider must be a
psychologist, a licensed professional counselor - mental health, a licensed professional
counselor working toward a mental health designation, a clinical nurse specialist, a certified
social worker-PIP, a certified social worker - PIP candidate, or a licensed marriage and
family therapist, or a licensed marriage and family therapist working toward a mental health
designation who has a signed provider agreement with the department to provide mental
health services.
A mental health provider must have a National Provider Identification (NPI) number
and may not provide services under another provider's medical assistance provider NPI
number.
An individual who does not meet the certification or licensure requirements of the
applicable profession may not enroll as a mental health provider or participate in the delivery
of mental health services, except for psychological or neuropsychological test administration
and scoring by a technician.
Source: 22 SDR 6, effective July 26, 1995; 26 SDR 168, effective July 1, 2000; 37
SDR 53, effective September 23, 2010; 40 SDR 122, effective January 7, 2014; 45 SDR 82,
effective December 10, 2018.
General Authority: SDCL 28-6-1(1)(2)(4).
Law Implemented: SDCL 28-6-1(1)(2)(4).
Cross-Reference: Provider requirements, ch 67:16:33.