(1) "Addiction counselor" means an individual who has met the standards established by the Board of Addiction and Prevention Professionals and is recognized as a Licensed Addiction Counselor or Certified Addiction Counselor, by the Board of Addiction and Prevention Professionals, or an addiction counselor employed by a recognized tribal program that has met the credentialing requirements required by Indian Health Service;

(2) "Adolescent" means a recipient, under the age of 21, who is eligible for medical assistance under article 67:46;

(3) "Certification team" means a team of medical professionals that determines if an adolescent is in need of substance use disorder treatment services;

(4) "Clinically-managed low-intensity residential treatment program" means an accredited residential treatment program providing services listed in chapter 67:61:16 to a client, in a structured environment designed to aid re-entry into the community;

(5) "Crisis intervention" means services that are:

(a) Provided to an individual experiencing a crisis related to the individual's use of alcohol or drugs, including a crisis in which co-occurring mental health symptoms are present; and;

(b) Focused on restoring the individual to the level of functioning before the crisis or providing a means to place the individual into a secure environment;

(6) "Day treatment program" means an accredited program providing services listed in chapter 67:61:15 to a client in a clearly defined, structured, intensive treatment program;

(7) "Department" means the Department of Social Services;

(8) "Division" means the Division of Behavioral Health within the Department of Social Services;

(9) Early intervention program" means an accredited nonresidential program providing services listed in chapter 67:61:12 to individuals who may have substance use related problems, but do not meet the diagnostic criteria for a substance use disorder;

(10) "Integrated assessment" means the process of a provider gathering information and engaging with a client, to establish the presence or absence of a co-occurring disorder, and to identify a client's strengths and needs, determine the client's motivation and readiness for change, and engage the client in the development of an appropriate treatment relationship in which an individualized treatment plan can be developed;

(11) "Intensive methamphetamine services" means a program that supports treatment services for a recipient who:

(a) Is 18 years of age or older;

(b) Is assessed with a severe methamphetamine use disorder; and

(12) "Intensive outpatient treatment program" means an accredited nonresidential program providing services listed in chapter 67:61:14 to a client in a clearly defined, structured, intensive outpatient treatment program on a regularly scheduled basis;

(13) "Medically-monitored intensive inpatient treatment program" means an accredited residential treatment program providing services listed in chapter 67:61:18 to a client in a structured environment;

(14) "Outpatient treatment program" means an accredited nonresidential program providing services listed in chapter 67:61:13 to a client or a person harmfully affected by alcohol or drugs through regularly scheduled counseling services;

(15) "Psychiatric residential treatment program" means residential substance use disorder treatment provided to adolescents in a psychiatric residential treatment facility that meets the requirements of 42 C.F.R. 441.151, as amended to July 1, 2016; and

(16) "Tribal program" means a tribal substance use disorder treatment program recognized by the division as meeting the requirements of § 67:16:48:14.

Source: 43 SDR 80, effective December 5, 2016; 44 SDR 192, effective July 2, 2018; 49 SDR 21, effective September 12, 2022.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1(1)(2).

Rule 67:16:48:02 Covered services.

67:16:48:02. Covered services. Substance use disorder treatment services covered under this chapter are limited to the following:

(1) The integrated assessment;

(2) Crisis intervention services;

(3) Early intervention services;

(4) Outpatient treatment programs;

(5) Intensive outpatient treatment programs;

(6) Day treatment programs;

(7) Clinically-managed low-intensity residential treatment programs;

(8) Medically-monitored intensive inpatient treatment programs; and

(9) Psychiatric residential treatment programs for substance use disorders.

Source: 43 SDR 80, effective December 5, 2016; 44 SDR 192, effective July 2, 2018; 46 SDR 50, effective October 10, 2019.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1(1).

Rule 67:16:48:03 Services not covered.

67:16:48:03. Services not covered. The following services are not covered under the provisions of this chapter:

(1) Treatment for a diagnosis of substance use disorder that exceeds the limits established by the division, unless prior authorization is approved by the division;

(2) Out-of-state substance use disorder treatment unless the division determines that appropriate in-state treatment is not available;

(3) Treatment for a gambling disorder;

(4) Room and board for residential services;

(5) Substance use disorder treatment before the integrated assessment is completed;

(6) Substance use disorder treatment after 30 days if the treatment plan has not been completed;

(7) Substance use disorder treatment if a required review has not been completed;

(8) Court appearances, staffing sessions, or treatment team appearances; and

(9) Substance use disorder services provided to a recipient incarcerated in a correctional facility.

Source: 43 SDR 80, effective December 5, 2016; 44 SDR 192, effective July 2, 2018.

General Authority: SDCL 28-6-1(1)(4).

Law Implemented: SDCL 28-6-1(1)(4).

Rule 67:16:48:04 Services requiring prior authorization.

67:16:48:04. Services requiring prior authorization. The following services require prior authorization:

(1) Medically-monitored intensive inpatient programs;

(2) Clinically-managed low intensity residential treatment programs for pregnant women or women with dependent children;

(3) Intensive methamphetamine services; and

(4) Psychiatric residential treatment programs.

Source: 43 SDR 80, effective December 5, 2016; 44 SDR 192, effective July 2, 2018.

General Authority: SDCL 28-6-1(1)(2)(4).

Law Implemented: SDCL 28-6-1(1)(2)(4).

Rule 67:16:48:05 Prior authorization requirements.

67:16:48:05. Prior authorization requirements. The requirements for prior authorization of a medically monitored intensive inpatient program, clinically-managed low-intensity residential treatment program for pregnant women or women with dependent children, and intensive methamphetamine services are as follows:

(1) An addiction counselor completes an integrated assessment, the assessment indicates a diagnosis of a substance use disorder, and the addiction counselor determines the recipient meets the criteria for placement in, transfer to, or continued stay in a substance use disorder treatment program;

(2) A physician or other licensed practitioner refers the recipient for placement in, transfer to, or continued stay in a substance use disorder treatment program and provides the division with written verification of pregnancy, if applicable; and

(3) The division authorizes the treatment.

Source: 43 SDR 80, effective December 5, 2016; 44 SDR 94, effective December 4, 2017; 44 SDR 192, effective July 2, 2018.

General Authority: SDCL 28-6-1(1)(2)(4).

Law Implemented: SDCL 28-6-1(1)(2)(4).

Rule 67:16:48:06 Prior authorization for psychiatric residential treatment programs for substance use disorders.

67:16:48:06. Prior authorization for psychiatric residential treatment programs for substance use disorders. The requirements for prior authorization of a psychiatric residential treatment program for a substance use disorder are as follows:

(1) An addiction counselor completes an integrated assessment, the assessment indicates a diagnosis of a substance use disorder, and the addiction counselor determines the adolescent meets the criteria for placement in, transfer to, or continued stay in a substance use disorder treatment program;

(2) A physician or other licensed practitioner refers the adolescent for placement in, transfer to, or continued stay in a substance use disorder treatment program;

(3) The division authorizes the treatment; and

(4) The certification team, based on medical documentation, determines the treatment is medically necessary and meets the requirements listed in 42 CFR 441.152, as amended to July 1, 2017. The certification team shall notify the division of their determination that medical necessity has been met or if the adolescent does not meet the severity of illness criteria.

Source: 43 SDR 80, effective December 5, 2016; 44 SDR 94, effective December 4, 2017.

General Authority: SDCL 28-6-1(1)(2)(4).

Law Implemented: SDCL 28-6-1(1)(2)(4).

Cross-Reference: Treatment for an adolescent with a substance use disorder -- Out-of-state, § 67:16:48:08.

Rule 67:16:48:07 Repealed.

67:16:48:07. Short-term relapse treatment for an adolescent with a substance use disorder. Repealed.

Source: 43 SDR 80, effective December 5, 2016; 44 SDR 94, effective December 4, 2017; 44 SDR 192, effective July 2, 2018.

Rule 67:16:48:08 Treatment for a substance use disorder -- Out-of-state.

67:16:48:08. Treatment for a substance use disorder -- Out-of-state. Out-of-state treatment for a substance use disorder is limited to those services provided in a facility which is licensed or accredited in another state as a substance use disorder treatment facility. Treatment is covered if the following additional requirements are met:

(1) An addiction counselor within that state completes an integrated assessment and sends the completed assessment to the division. The assessment must include a biopsychosocial history with appropriate testing instrument scores, indicate a diagnosis of a substance use disorder, and contain the credentials of the counselor completing the assessment;

(2) For intensive inpatient treatment or psychiatric residential treatment, a physician or other licensed practitioner refers the recipient for placement in, transfer to, or continued stay in a substance use disorder treatment program;

(3) The division authorizes the treatment, and no appropriate in-state treatment is available; and

(4) The psychiatric residential treatment provided meets the prior authorization requirements found in § 67:16:48:06.

Out-of-state outpatient services do not require prior authorization when provided within 50 miles of the South Dakota border.

Source: 43 SDR 80, effective December 5, 2016; 44 SDR 94, effective December 4, 2017; 44 SDR 192, effective July 2, 2018.

General Authority: SDCL 28-6-1(1)(2).

Law Implemented: SDCL 28-6-1(1)(2).

Rule 67:16:48:09 Repealed.

67:16:48:09. Treatment for a pregnant woman with a substance use disorder -- In-state. Repealed.

Source: 43 SDR 80, effective December 5, 2016; 44 SDR 94, effective December 4, 2017; 44 SDR 192, effective July 2, 2018.

Rule 67:16:48:10 Repealed.

67:16:48:10. Treatment for a pregnant woman with a substance use disorder -- Out-of-state. Repealed.

Source: 43 SDR 80, effective December 5, 2016; 44 SDR 94, effective December 4, 2017; 44 SDR 192, effective July 2, 2018.

Rule 67:16:48:11 Prior authorization required for care beyond established service limit.

67:16:48:11. Prior authorization required for care beyond established service limit. Prior authorization by the division is required for a continued stay beyond the length-of-stay service limits. The provider shall submit to the division the documentation required in § 67:61:07:07. Based on the documentation submitted, the division shall determine whether the recipient's current level of care is appropriate.

Source: 43 SDR 80, effective December 5, 2016.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

Rule 67:16:48:12 Rate of payment -- Treatment for a substance use disorder.

67:16:48:12. Rate of payment -- Treatment for a substance use disorder. A service covered under this chapter is subject to the limits listed on the department's billing guidance website. Payment for the treatment of a substance use disorder covered under this chapter is limited to the provider's usual and customary charge or the fee established by the division, whichever is less. The covered procedures and the associated procedure codes are found on the department's fee schedule website.

The services described in § 67:61:18:02 are included in the daily rate.

Source: 43 SDR 80, effective December 5, 2016; 44 SDR 192, effective July 2, 2018.

General Authority: SDCL 28-6-1(1)(2)(4).

Law Implemented: SDCL 28-6-1(1)(2)(4).

Rule 67:16:48:13 Claim requirements -- Substance use disorders.

67:16:48:13. Claim requirements -- Substance use disorders. A claim for a substance use disorder treatment service provided under this chapter shall be submitted to the department on a form or in an electronic format and shall contain the following information:

(1) The recipient's full name;

(2) The recipient's medical assistance identification number from the recipient's medical assistance identification card;

(3) Third-party liability information required under chapter 67:16:26;

(4) Date of service;

(5) Place of service;

(6) The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge;

(7) The applicable procedure codes for the covered services provided;

(8) The applicable diagnosis codes as adopted in § 67:16:01:26;

(9) The units or days of service furnished, if more than one;

(10) The provider's name and National Provider Identification (NPI) number; and

(11) The prior authorization number issued to the provider by the division for services that require prior authorization.

A separate claim form must be used for each recipient.

Source: 43 SDR 80, effective December 5, 2016.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

Note: The CMS 1500 form substantially meets the requirements of this rule and its content and appearance is acceptable. These forms are available for direct purchase through the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402.

(202) 783-3238 - pricing desk.

Rule 67:16:48:14 Recognizing a tribal program as a participating provider.

67:16:48:14. Recognizing a tribal program as a participating provider. A tribal substance use disorder treatment program seeking to participate as a provider under the provisions of this chapter shall submit all of the following information to the division:

(1) A written request from the tribal chairman to the secretary of the Department requesting permission for the program to provide services to a recipient under this chapter;

(2) A copy of the last onsite review conducted by Indian Health Service that indicates the program obtained the minimum points necessary to provide services for the level of care being provided;

(3) A written statement signed by the program director that states the program has met the minimum national or applicable state or Indian Health Service standards for the level of care provided, and a statement that the program is in good standing with Indian Health Services;

(4) A copy of the contract the tribe has with Indian Health Service pursuant to the provisions of Pub. L. 93-638 (the Indian Self-Determination Act), effective January 4, 1975; and

(5) A copy of the signed provider agreement between the Department and the tribe.

The division may not recognize a tribal program as a participating provider until the division is in possession of all the documentation required in this section. Recognition of a tribal program is subject to annual review and approval by the division.

Source: 43 SDR 80, effective December 5, 2016; 44 SDR 192, effective July 2, 2018.

General Authority: SDCL 28-6-1(4)(6).

Law Implemented: SDCL 28-6-1(4)(6).

Rule 67:16:48:15 Application of other chapters.

67:16:48:15. Application of other chapters. In addition to the rules contained in this chapter, providers and recipients shall meet the requirements of chapters 67:16:01, 67:16:26, 67:16:33, 67:16:34, and 67:16:35.

Source: 43 SDR 80, effective December 5, 2016.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

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