Terms used in this article mean:

1. (1) "Allowable costs," expenses incurred in meeting state licensure or federal certification standards for the provision of medical services;
2. (2) "Applicant," an individual who has filed an application for participation in the medical assistance program;
3. (3) "Claim form" or "claim," a communication used by providers to request payment for goods or services reimbursable under this article;
4. (4) "Centers for Medicare and Medicaid Services" or "CMS," the federal agency that administers the Medicare program and monitors the Medicaid programs offered by each state;
5. (5) "Cost sharing," money paid by a recipient to a provider for each covered service or procedure rendered to the recipient or on the recipient's behalf;
6. (6) "Department," the Department of Social Services;
7. (7) "Disability/incapacity consultation team," a three-member team consisting of a registered nurse, a social worker from the department, and a consultant physician;
8. (8) "Emergency," a condition that if not immediately diagnosed and treated could cause a person serious physical or mental disability, continuation of severe pain, or death;
9. (9) "Medicaid," the program authorized by Title XIX of the Social Security Act, 42 U.S.C. § 1396d, as amended to July 1, 2017, which covers the allowable medical expenses of eligible individuals;
10. (10) "Medical assistance" or "medical assistance program," the Medicaid program authorized by Title XIX of the Social Security Act, 42 U.S.C. § 1396d, as amended to July 1, 2017, and SDCL 28-6, 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;
11. (11) "Other licensed practitioner," a physician assistant, nurse practitioner, clinical nurse specialist, nurse midwife, or nurse anesthetist who is licensed by the state to provide services and is performing within their scope of practice under the provisions of SDCL title 36;
12. (12) "Prior authorization," written approval issuing authorization by the department to a provider before certain covered services may be provided;
13. (13) "Provider," an individual or entity that has a provider agreement with the department and provides Medicaid services under the agreement;
14. (14) "Reasonable costs," that portion of allowable costs that will be paid for a given medical service;
15. (15) "Recipient," a person who is determined by the department to be eligible for services under this article;
16. (16) "SSI," supplemental security income;
17. (17) "Usual, customary charge" or "usual and customary," the individual provider's normal charge to the general public for a specific service on the day the service was provided 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; and

18. (18) "Website," the webpage on the department's website that contains specific information referred to in this chapter. The following websites are used in this chapter.

    Billing Guidance Website: http://dss.sd.gov/medicaid/providers/billingmanuals/

    Cost Sharing Website: http://dss.sd.gov/medicaid/recipients/costsharing.aspx

    Fee Schedule Website: http://dss.sd.gov/medicaid/providers/feeschedules/dss/

    Modifier Website: http://dss.sd.gov/medicaid/modifiers.aspx

    Pharmacy Website: http://dss.sd.gov/medicaid/providers/programinfo/pharmacy/

    Prior Authorization Website: http://dss.sd.gov/medicaid/providers/pa/

Source: SL 1975, ch 16, § 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 ; 43 SDR 80, effective December 5, 2016 ; 44 SDR 94, effective December 4, 2017.

General Authority: SDCL 28-6-1 (1)(2)(4)(6) , 42 U.S.C. § 1396d.

Law Implemented: SDCL 28-6-1(1)(2)(4)(6) , 42 U.S.C. § 1396d.

Prior versions effective: 2016-12-05, 2015-10-13, 2014-01-07.