<html> <head> <title>Rule 67:16:01:01 Definitions.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:01:01"> <META NAME="Description" Content="Administrative Rules 67:16:01:01 Definitions."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 15 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:"Cambria Math"; panose-1:2 4 5 3 5 4 6 3 2 4;} @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:10.0pt; font-family:"Times",serif; color:black;} a:link, span.MsoHyperlink {color:blue; text-decoration:underline;} a:visited, span.MsoHyperlinkFollowed {color:purple; text-decoration:underline;} .MsoChpDefault {font-size:10.0pt; color:black;} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US link=blue vlink=purple> <div class=WordSection1> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:01:01.&nbsp;&nbsp;Definitions.</b> Terms used in this article mean:</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;&quot;Allowable costs,&quot; expenses incurred in meeting state licensure or federal certification standards for the provision of medical services;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;&quot;Applicant,&quot; an individual who has filed an application for participation in the medical assistance program;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;&quot;Claim form&quot; or &quot;claim,&quot; a communication used by providers to request payment for goods or services reimbursable under this article;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (4)&nbsp;&nbsp;&quot;Centers for Medicare and Medicaid Services&quot; or &quot;CMS,&quot; the federal agency that administers the Medicare program and monitors the Medicaid programs offered by each state;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (5)&nbsp;&nbsp;&quot;Cost sharing,&quot; money paid by a recipient to a provider for each covered service or procedure rendered to the recipient or </span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>o</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>n the recipient's behalf;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (6)&nbsp;&nbsp;&quot;Department,&quot; the Department of Social Services;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (7)&nbsp;&nbsp;&quot;Disability/incapacity consultation team,&quot; a three-member team consisting of a registered nurse</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> a social worker from the department</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> and a consultant physician;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (8)&nbsp;&nbsp;&quot;Emergency,&quot; a condition that if not immediately diagnosed and treated could cause a person serious physical or mental disability, continuation of severe pain, or death;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (9)&nbsp;&nbsp;&quot;Medicaid,&quot; the program authorized by Title XIX of the Social Security Act, 42 U.S.C. &#167;&nbsp;1396d, as amended to July 1, 201</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>7</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>, which covers the allowable medical expenses of eligible individuals;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (10)&nbsp;&nbsp;&quot;Medical assistance&quot; or &quot;medical assistance program,&quot; the Medicaid program authorized by Title XIX of the Social Security Act, 42 U.S.C. &#167;&nbsp;1396d, as amended to July 1, 201</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>7</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>, and SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6">28-6</A>, which provides medical assistance to eligible individuals; assistance provided to children who qualify for the non-Medicaid children's health insurance program covered under the provisions of chapter 67:46:14;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (11)&nbsp;&nbsp;&quot;Other licensed practitioner</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&quot; a physician assistant, nurse practitioner, clinical nurse</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>specialist, nurse midwife, or nurse anesthetist who is licensed by the state to provide services and</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>is performing within their scope of practice under the provisions of SDCL title <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=36">36</A>;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>(12)&nbsp;&nbsp;</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&quot;Prior authorization,&quot; written approval issu</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>i</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>n</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>g</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> authorization by the department to a provider before certain covered services may be provided;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>(13)&nbsp;&nbsp;&quot;Provider,&quot; an individual or entity that has a provider agreement with the department and provides Medicaid services under the agreement;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>4</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>)&nbsp;&nbsp;&quot;Reasonable costs,&quot; that portion of allowable costs that will be paid for a given medical service;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>5</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>)&nbsp;&nbsp;&quot;Recipient,&quot; a person who is determined by the department to be eligible for services under this article;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>6</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>)&nbsp;&nbsp;&quot;SSI,&quot; supplemental security income;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>7</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>)&nbsp;&nbsp;&quot;Usual, customary charge&quot; or &quot;usual and customary,&quot; the individual provider's normal charge to the general public for a specific service on the day the service was provided</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> within the range of charges made by similar providers for such services and consistent with the prevailing market rates in the geographic area for comparable services</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>; and</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>8</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>)&nbsp;&nbsp;&quot;Website,&quot; the webpage on the department's website that contains specific information referred to in this chapter. The following websites are used in this chapter.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Billing Guidance Website: </span><a href="http://dss.sd.gov/medicaid/providers/billingmanuals/"><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>http://dss.sd.gov/medicaid/providers/billingmanuals/</span></a></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Cost Sharing Website: </span><a href="http://dss.sd.gov/medicaid/recipients/costsharing.aspx"><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>http://dss.sd.gov/medicaid/recipients/costsharing.aspx</span></a></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Fee Schedule Website: </span><a href="http://dss.sd.gov/medicaid/providers/feeschedules/dss/"><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>http://dss.sd.gov/medicaid/providers/feeschedules/dss/</span></a></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Modifier Website: </span><a href="http://dss.sd.gov/medicaid/modifiers.aspx"><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>http://dss.sd.gov/medicaid/modifiers.aspx</span></a></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Pharmacy Website: </span><a href="http://dss.sd.gov/medicaid/providers/programinfo/pharmacy/"><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>http://dss.sd.gov/medicaid/providers/programinfo/pharmacy/</span></a></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Prior Authorization Website: </span><a href="http://dss.sd.gov/medcaid/providers/pa/"><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>http://dss.sd.gov/med</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>i</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>caid/providers/pa/</span></a></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> SL 1975, ch 16, &#167;&nbsp;1; 7 SDR 23, effective September 18, 1980; 7 SDR 76, effective February 11, 1981; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 9 SDR 164, effective June 30, 1983; 14 SDR 46, effective September 28, 1987; 15 SDR 2, effective July 17, 1988; 17 SDR 4, effective July 16, 1990; 18 SDR 67, effective October 13, 1991; 26 SDR 168, effective July 1, 2000; 37 SDR 53, effective September 23, 2010; 40 SDR 122, effective January 7, 2014; 42 SDR 51, effective October 13, 2015</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>; 43 SDR 80, effective December 5, 2016</span><span style='font-size:12.0pt;font-family: "Times New Roman",serif'>; 44 SDR 94, effective December 4, 2017.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1</A></span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>(1)(2)(4)(6)</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>, 42 U.S.C. §&nbsp;1396d.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1(1)(2)(4)(6)</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=42">42</A> U.S.C. § 1396d.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> </div> </body> </html>