Covered services are those medically necessary health care services or items that are within the service limits and meet the prior authorization requirements specified in this article or article 67:54. The department will pay for a medically necessary covered service furnished to a recipient or to a person who is found to be eligible on the date of service.

Prior authorization is based on a review of required documentation to determine if the conditions for Medicaid payment have been met. The review is not considered a medical consultation.

Cross-References: Case management -- Primary care provider, ch 67:16:39; Covered services must be medically necessary, § 67:16:01:06.02.

Source: 17 SDR 4, effective July 16, 1990; 17 SDR 194, effective June 24, 1991; 19 SDR 26, effective August 23, 1992; 20 SDR 135, effective February 22, 1994; 23 SDR 8, effective July 21, 1996.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.