<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.s866a9c38-2d8d-451d-b96d-688410ee9731P0 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: justify; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; } span.s866a9c38-2d8d-451d-b96d-688410ee9731C0 { color: #000000; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s866a9c38-2d8d-451d-b96d-688410ee9731C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s866a9c38-2d8d-451d-b96d-688410ee9731C0-000001 { color: #000000; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s866a9c38-2d8d-451d-b96d-688410ee9731000002 { color: #000000; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s866a9c38-2d8d-451d-b96d-688410ee9731C0-000003 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:29:04.02"><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0-000000">67:16:29:04.02</span></a><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0-000001">.  Provider to maintain </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0-000001">records</span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0-000001">.</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> The provider</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> </span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">prescribing medical equipment must document the </span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">medical necessity in the recipient's </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">med</span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">ical record.</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">Unless otherwise specified in the department's coverage criteria, the provider shall update the medical necessity documentation</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> annually or when the physician or other licensed practitioner's estimated quantity, frequency, or duration is changed prior to the annual renewal.</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> Failure to properly </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">document</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> medical necessity is cause for nonpayment.</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731000002"> </span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    The medical </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">record</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> must contain:</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731000002"> </span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    (1)</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">  </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">Recipient name and Medicaid ID number;</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    (2)</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">  </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">Diagnosis, including an explanation of the particular condition resulting from the</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">diagnosis which relates to the equipment request;</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    (3)</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">  </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">Prognosis;</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    (4)</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">  </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">Length of time the item is expected to be required;</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    (5)</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">  </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">Justification of medical necessity;</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    (6)</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">  </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">Equipment prescribed;</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    (7)</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">  Prescrib</span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">ing provider's National Provider Identification number, signature, and</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">date signed;</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    (8)</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">  </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">Description of equipment;</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> and</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    (9)</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">  </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">Explanation of equipment functions</span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">.</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731000002"> </span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0-000001">Source:</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> 18 SDR 210, effective June 23, 1992; 41 SDR 93, effective December 3, 2014</span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">; 44 SDR 94, effective December 4, 2017; 47 SDR 38, effective October 6, 2020</span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">; 50 SDR 63, effective November 27, 2023</span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">.</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0-000001">General Authority:</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0-000003">28-6-1</span></a><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">.</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">    </span><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0-000001">Law Implemented:</span><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0-000003">28-6-1</span></a><span class="s866a9c38-2d8d-451d-b96d-688410ee9731C0">.</span></p><p dir="ltr" class="s866a9c38-2d8d-451d-b96d-688410ee9731P0"><span xml:space="preserve" class="s866a9c38-2d8d-451d-b96d-688410ee9731000002"> </span></p></div></body></html>