The department does not cover and the provider may not submit a claim for:

1. (1) Mental health services not defined in § 67:16:41:01;
2. (2) Mental health treatment provided without the recipient physically present in a face-to-face session with the mental health provider, except for telehealth treatment and collateral contact;
3. (3) Treatment for a mental health disorder not included in the diagnosis codes set forth in § 67:16:41:05;
4. (4) Mental health treatment provided before a diagnostic assessment is completed, except treatment provided with a provisional diagnosis of a mental health disorder during the thirty-day time period the mental health provider has to complete the diagnostic assessment;
5. (5) Mental health treatment provided after thirty days from the date of intake, if a treatment plan has not been completed;
6. (6) Mental health treatment provided if a required treatment plan review has not been completed;
7. (7) Court appearance, staffing sessions, or treatment team appearances;
8. (8) Mental health services provided to a recipient incarcerated in a correctional facility;
9. (9) Mental health services provided to a recipient in an institution for mental diseases or an intermediate care facility for individuals with intellectual disabilities;
10. (10) Mental health treatment that does not demonstrate a reasonably timed continuum of progress toward the specific goals stated in the treatment plan, as determined by the peer review entity;
11. (11) Mental health treatment that is not listed in the treatment plan or documented in the recipient's clinical record, even though the service is allowable under this chapter;

12. (12) Mental health treatment provided to a recipient who is:

    1. (a) Incapable of cognitive functioning due to age or mental incapacity; or
    2. (b) Unable to receive any benefit from the service;
13. (13) Mental health services performed without relationship to evaluations or psychotherapy for a specific condition, symptom, or complaint;
14. (14) Time spent preparing reports, treatment plans, or clinical records outside the scope of covered procedure codes;
15. (15) A service designed to assist a recipient regulate a bodily function controlled by the autonomic nervous system, by using an instrument to monitor the function and signal the changes in the function;
16. (16) Alcohol or drug rehabilitation therapy;
17. (17) Missed or canceled appointments;
18. (18) Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family members or another responsible person;
19. (19) Medical hypnotherapy;
20. (20) Field trips and other off-site activities;
21. (21) Consultations or meetings between an employer and employee;
22. (22) Review of work product by the treating mental health provider;
23. (23) Telephone consultations with or on behalf of the recipient, except for collateral contact;

24. (24) Educational, vocational, socialization, or recreational services, or components of services, including:

    1. (a) Activity group therapy;
    2. (b) Assertiveness training;
    3. (c) Bioenergetics therapy;
    4. (d) Consciousness training;
    5. (e) Dance therapy;
    6. (f) Day care;
    7. (g) Educational activities;
    8. (h) Family counseling;
    9. (i) Growth groups or psychotherapy for nonspecific conditions of distress;
    10. (j) Guided imagery;
    11. (k) Marital counseling;
    12. (l) Marriage enrichment;
    13. (m) Milieu therapy;
    14. (n) Music therapy;
    15. (o) Obesity control therapy;
    16. (p) Occupational therapy;
    17. (q) Parental counseling or bonding;
    18. (r) Peer relations therapy;
    19. (s) Play observation;
    20. (t) Primal scream therapy;
    21. (u) Recorded psychotherapy;
    22. (v) Recreational therapy;
    23. (w) Religious counseling;
    24. (x) Rolfing or structural integration;
    25. (y) Sensitivity training;
    26. (z) Sex therapy;
    27. (aa) Sleep observation;
    28. (bb) Tape therapy;
    29. (cc) Training disability service;
    30. (dd) Vocational counseling; and
    31. (ee) Z-therapy; and

25. (25) Mental health treatment delivered in excess of the frequency prescribed in the treatment plan.

    Cross-References:

    Treatment plan, § 67:61:07:06.

    Treatment plan, § 67:62:08:07.

    Treatment plan review -- Six month review, § 67:62:08:08.

Source: 22 SDR 6, effective July 26, 1995; 26 SDR 168, effective July 1, 2000; 37 SDR 53, effective September 23, 2010; 40 SDR 122, effective January 8, 2014 ; 45 SDR 82, effective December 10, 2018 ; 46 SDR 50, effective October 10, 2019; 48 SDR 39, effective October 3, 2021; 49 SDR 21, effective September 12, 2022; 50 SDR 63, effective November 27, 2023 .

General Authority: SDCL 28-6-1 .

Law Implemented: SDCL 28-6-1 .

Prior versions effective: 2022-09-12, 2021-10-03, 2019-10-10, 2018-12-10, 2014-01-08.