22:02:02:01.  Board meetings. Board meetings are subject to call. Interested individuals must contact the association or a CCPR board member to request a meeting with the board.

          Source: 11 SDR 144, effective May 2, 1985; 19 SDR 76, effective November 23, 1992; transferred from § 67:19:02:01, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:02.  Board member conflict of interest. If a claim for reimbursement is submitted from a board member's county, that board member may participate in the discussions concerning the claim but may not participate in the board's final vote of approval or disapproval.

          Source: 11 SDR 144, effective May 2, 1985; transferred from § 67:19:02:02, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:03.  Notice of imminent claim -- Deadline for notifying board of amount of delayed claim. A county shall notify the association in writing as soon as possible if a claim appears to be imminent. If the county's application for CCPR fund reimbursement for the claim is going to be delayed, the county shall provide written notification to the association of the amount of the claim no later than the end of the calendar year following the year the county is billed for the medical expenses.

          Source: 11 SDR 144, effective May 2, 1985; transferred from § 67:19:02:03, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:04.  Determination of 12-month period. A 12-month period begins the first day an eligible individual incurs hospital or other medical expenses used in establishing or computing a CCPR payment. A 12-month period ends at 12:01 a.m. on the anniversary of the first date the expenses were incurred.

          Source: 11 SDR 144, adopted May 2, 1985, effective July 1, 1985; 19 SDR 76, effective November 23, 1992; transferred from § 67:19:02:04, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:05.  Application for reimbursement -- Evidence of payment. A county requesting reimbursement from the CCPR fund must submit an application for reimbursement to the association on a form available from the association.

          In addition to the application, a county must provide the following information to the association:

          (1)  A copy of the provider's invoice showing dates of service;

          (2)  Evidence, such as a copy of the approved county voucher, that payment was made by the county, including the amount paid;

          (3)  If the request for reimbursement is for a hospital claim incurred after June 30, 1997, documentation which establishes both the individual's and the county's share of the hospital bill;

          (4)  If county payment to a hospital was based on the Medicaid rate, a copy of the documentation from Medicaid which calculates the Department of Social Services payment rate; and

          (5)  A voucher signed by the county board of commissioners chair or vice-chair.

          If the claim being submitted is the first reimbursement request covering a particular individual, the county must also submit evidence which shows that the county has met its $20,000 share of the expenses for that individual for the 12-month period in which the services were rendered.

          If the claim is for an organ transplant, the county must submit evidence of compliance with SDCL 28-13A-13.

          Source: 11 SDR 144, effective May 2, 1985, amended effective July 1, 1985; 13 SDR 134, effective March 30, 1987; 19 SDR 76, effective November 23, 1992; 25 SDR 69, effective November 12, 1998; transferred from § 67:19:02:05, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4, 28-13A-6.

          22:02:02:06.  Claim approval process. The association shall return an application for reimbursement containing insufficient information or evidence to the county for completion and resubmission.

          After receipt of the county's application, supporting documentation, and the association's recommendations, the board shall review the claim and approve, deny, or adjust the payment.

          The board shall notify the county in writing if the claim is denied. The notice shall contain the reasons for the denial and shall be sent by certified mail within 10 working days after the decision is rendered.

          Source: 11 SDR 144, effective May 2, 1985; 13 SDR 134, effective March 30, 1987; 22 SDR 2, effective July 17, 1995; 25 SDR 69, effective November 12, 1998; transferred from § 67:19:02:06, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4, 28-13A-6, 28-13A-7.

          Cross-Reference: Review procedure, § 22:02:01:08.

          22:02:02:07.  Reasons for claim denial. The board shall deny a county's claim for reimbursement for any of the following reasons:

          (1)  The county has not paid its CCPR annual assessment;

          (2)  The county has not paid its supplemental CCPR fund assessment;

          (3)  The county has not paid the first $20,000 for the individual for the 12-month period;

          (4)  The county has not provided the evidence required under § 22:02:02:05;

          (5)  The service was provided before January 1, 1985;

          (6)  The service was provided before the date of county participation;

          (7)  The county has not been approved as a participating county;

          (8)  The request for reimbursement has been delayed and the county failed to notify the department according to § 22:02:02:03;

          (9)  The claim is for an organ transplant for which the county has failed to meet the requirements of SDCL 28-13A-13;

          (10)  The county failed to follow its guidelines when determining eligibility;

          (11)  The county failed to pursue other third-party payment sources;

          (12)  The individual was not eligible for county poor relief; or

          (13)  The claim exceeds the payment limits established in § 22:02:02:08.

          Source: 11 SDR 144, effective May 2, 1985, amended effective July 1, 1985; 19 SDR 76, effective November 23, 1992; 22 SDR 2, effective July 17, 1995; 25 SDR 69, effective November 12, 1998; transferred from § 67:19:02:07, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:08.  Payment limits. If a county has negotiated final payment with a provider, the CCPR fund shall reimburse 90 percent of the negotiated amount, less the county's $20,000 share, if applicable.

          The rate of reimbursement from the CCPR fund for a hospital expense may not exceed the limits established in SDCL 28-13-29.

          If a county carries an individual over into a new 12-month period, the individual's medical expenses for the new 12-month period must exceed $20,000 before the individual's medical expenses are again eligible for reimbursement from the CCPR fund.

          Source: 11 SDR 144, effective May 2, 1985, and July 1, 1985; 25 SDR 69, effective November 12, 1998; transferred from § 67:19:02:08, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4, 28-13A-7.

          22:02:02:09.  Repayment to CCPR fund if county collects on claims. If a county receives a CCPR reimbursement to cover an individual's medical claims and the county subsequently collects all or part of the claims from either the individual or a third-party source, the county shall repay a percentage of the collection to the CCPR fund. The percentage of the collection to be repaid equals the percentage of the claims that the CCPR reimbursement represents.

          Source: 13 SDR 134, effective March 30, 1987; transferred from § 67:19:02:09, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:10.  County to pursue third-party payment sources. Because the county is the payor of last resort, a county must pursue the availability of a third-party payment source before accepting responsibility for a catastrophic claim. A third-party payment source is the obligation of an entity other than the county for either partial or full payment of the medical cost of injury, disease, or disability. Third-party payment sources include coverage such as Medicare, Medicaid, private health insurance, workers' compensation, supplemental security income, disability insurance, and automobile insurance.

          The county must be able to document pursuit of the availability of a third-party payment source. The documentation must be maintained in the individual's record. When the claim is subsequently submitted to the CCPR program for payment, evidence of the third-party payment or rejection must accompany the claim.

          Source: 22 SDR 2, effective July 17, 1995; transferred from § 67:19:02:10, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.