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Administrative Rules

    67:16:41:09.  Covered mental health services -- Limits -- Payments. Payment for mental health services is the lesser of the provider's usual and customary charge or the fee listed on the department's fee schedule website. If no fee is listed, payment is 40 percent of the provider's usual and customary charge.

    Mental health services and associated rates of payment are subject to review and amendment under § 67:16:01:28.

    Payment for psychiatric therapeutic procedures is limited to those recipients who have received a primary diagnosis of a mental health disorder or a provisional diagnosis of a mental health disorder during the 30-day time period that the mental health provider has to complete the diagnostic assessment.

    Time units are for face-to-face or telehealth session times with the recipient or a collateral contact and do not include time used for traveling, reporting, charting, or other administrative functions outside the scope of the covered procedure codes.

    The maximum allowable coverage for psychotherapy services may not exceed 40 hours of therapy in a 12-month period, unless prior authorization has been received from the department. For purposes of this limit, procedure codes without an associated time are considered to be one hour.

    Source: 22 SDR 6, effective July 26, 1995; 25 SDR 104, effective February 17, 1999; 35 SDR 49, effective September 10, 2008; 37 SDR 53, effective September 23, 2010; 42 SDR 51, effective October 13, 2015; 45 SDR 82, effective December 10, 2018; 48 SDR 39, effective October 3, 2021; 49 SDR 21, effective September 12, 2022.

    General Authority: SDCL 28-6-1.

    Law Implemented: SDCL 28-6-1(1)(2)(4), 28-6-1.1.