When computing the rate of reimbursement, the department uses the fee schedules established under the provisions of § 67:16:02:01.01. A claim submitted under this chapter must be submitted at the provider's usual and customary charge. Payment is limited to the lesser of the provider's usual and customary charge or the payment established under the following provisions:

1. (1) For nonlaboratory procedures listed in the applicable fee schedule, the amount specified in the fee schedule;
2. (2) If no fee is specified for nonlaboratory procedures, payment is limited to forty percent of the usual and customary charge;
3. (3) For laboratory procedures listed in the applicable fee schedule, the amount specified in the fee schedule;
4. (4) If no fee is specified for laboratory procedures, payment is limited to sixty percent of the provider's usual and customary charge;
5. (5) For anesthesia services furnished by a physician, the fee established in the fee schedule on the department's fee schedule website. Time must be reported in fifteen-minute units beginning from the time the physician begins to prepare the patient for induction and ending when the patient is placed under postoperative supervision and the physician is no longer in personal attendance;
6. (6) For anesthesia services furnished by a nurse anesthetist, the fee established in the fee schedule on the department's fee schedule website, computed according to subdivision (5) of this section for as long as the anesthetist is assisting the physician in the care of the patient;
7. (7) For medical supplies incidental to the professional service provided, the fee established in the nonlaboratory fee schedule. If no fee is specified for the medical supplies, payment is limited to ninety percent of the lesser of the provider's usual and customary charge or the manufacturer's suggested retail price;
8. (8) For injection and immunization procedures, the amount established in the nonlaboratory fee schedule. If no fee is specified, payment is limited to forty percent of the provider's usual and customary charge; and
9. (9) For prosthetic or orthotic devices or medical equipment provided by a physician, the fee established in the nonlaboratory fee schedule. If no fee is specified, payment is limited to seventy-five percent of the lesser of the provider's usual and customary charge or the manufacturer's suggested retail price.

Source: SL 1975, ch 16, § 1; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 16 SDR 64, effective October 8, 1989; 16 SDR 214, effective June 11, 1990; 16 SDR 234, effective July 2, 1990; 17 SDR 200, effective July 1, 1991; 18 SDR 78, effective November 4, 1991; 18 SDR 107, effective December 29, 1991; 20 SDR 28, effective August 31, 1993; 26 SDR 168, effective July 1, 2000; 34 SDR 68, effective September 12, 2007; 37 SDR 236, effective June 28, 2011; 37 SDR 236, adopted June 8, 2011, effective July 1, 2012; 40 SDR 229, effective June 30, 2014; 42 SDR 51, effective October 13, 2015; 44 SDR 94, effective December 4, 2017 ; 50 SDR 63, effective November 27, 2023 .

General Authority: SDCL 28-6-1 .

Law Implemented: SDCL 28-6-1 , 28-6-1 .1 .

Prior versions effective: 2017-12-04, 2015-10-13, 2014-06-30, 2012-07-01.