<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.s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0 { 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.s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000001 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s2c75d58f-da7f-4c61-bc41-f197cf9311d8000002 { background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } a.s2c75d58f-da7f-4c61-bc41-f197cf9311d8000003 { text-decoration: none; } span.s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000004 { 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="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:03:06.01"><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000000">67:16:03:06.01</span></a><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000001">.  Basis of reimbursement -- Outpatient services.</span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0"> Reimbursement for all outpatient hospital</span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0"> </span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">services for prospective payment system hospitals </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">are</span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0"> paid using the </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">m</span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">edicaid</span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0"> </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">agency's outpatient prospective payment system (OPPS).</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8000002"> </span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">    </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">Reimbursement for</span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0"> in-state non-prospective payment system hospitals is made using a percent of charge rate </span><a id="_Hlk225522128" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8000003"></a><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">that approximates a minimum of one hundred percent of cost, not to exceed ninety percent of billed charges. The percent of charge rates are </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">published on the department's fee schedule website.</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8000002"> </span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">    </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">O</span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">ut-of-state hospital outpatient services</span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0"> must be paid using the medicaid agency's OPPS</span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">.</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8000002"> </span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">    Outpatient hospital dialysis services are reimbursed at the reimbursement rate published on the department's fee schedule website.</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8000002"> </span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">    Costs for outpatient services incurred within </span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">the </span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">three days immediately preceding the inpatient stay are included in the inpatient charges </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">if:</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8000002"> </span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">    (1)  T</span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">he outpatient service is related to the inpatient stay</span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">; and</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8000002"> </span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">    (2)  The inpatient and outpatient services are provided by the same hospital.</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8000002"> </span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">    Except for </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">m</span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">edicare prospective payment system hospitals, </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">o</span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">utpatient laboratory services are excluded from the provisions of this rule and are payable according to § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:03:06.07"><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000004">67:16:03:06.07</span></a><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">.</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8000002"> </span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">    </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000001">Source:</span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0"> 12 SDR 6, effective July 28, 1985; 15 SDR 2, effective July 17, 1988; 16 SDR 235, effective July 5, 1990; 17 SDR 180, effective May 27, 1991; 18 SDR 198, effective June 3, 1992; 22 SDR 143, effective May 9, 1996; 23 SDR 232, effective July 10, 1997; 25 SDR 116, effective March 24, 1999; 30 SDR 26, effective September 3, 2003; 31 SDR 107, effective February 1, 2005; 36 SDR 215, effective July 1, 2010; 36 SDR 215, adopted June 11, 2010, effective July 1, 2011; 37 SDR 236, effective June 28, 2011; 37 SDR 236, adopted June 8, 2011, effective July 1, 2012; 39 SDR 15, effective August 6, 2012; 40 SDR 15, effective July 31, 2013</span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">; 43 SDR 80, effective December 5, 2016; 52 SDR 126, effective July 1, 2026</span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">.</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">    </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000001">General Authority:</span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000004">28-6-1</span></a><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">.</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">    </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000001">Law Implemented:</span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000004">28-6-1</span></a><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">, </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1.1"><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000004">28-6-1.1</span></a><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">.</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8000002"> </span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">    </span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000001">Cross-</span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000001">Reference:</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000001">    </span><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">Definitions, "Website" (Fee Schedule Website), subdivision </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:01:01"><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0-000004">67:16:01:01</span></a><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">(18)</span><span class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8C0">.</span></p><p dir="ltr" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8P0"><span xml:space="preserve" class="s2c75d58f-da7f-4c61-bc41-f197cf9311d8000002"> </span></p></div></body></html>