S.D. Admin. R. 67:16:02:03

Current through Register Vol. 50, page 162, June 24, 2024

Section 67:16:02:03 - Rate of payment

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) For nonlaboratory procedures listed in the applicable fee schedule, the amount specified in the fee schedule;

(2) If no fee is specified for nonlaboratory procedures, payment is limited to forty percent of the usual and customary charge;

(3) For laboratory procedures listed in the applicable fee schedule, the amount specified in the fee schedule;

(4) If no fee is specified for laboratory procedures, payment is limited to sixty percent of the provider's usual and customary charge;

(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) 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 as long as the anesthetist is assisting the physician in the care of the patient;

(7) For medical supplies incidental to the professional service provided, the fee established in the nonlaboratory fee schedule. If no fee is specified, 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) 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) 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.

S.D. Admin. R. 67:16:02:03

SL 1975, ch 16; 42 SDR 51, effective 10/13/2015; 44 SDR 94, effective 12/4/2017; 50 SDR 063, effective 11/27/2023

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1(1)(2), 28-6-1.1.