Rule 67:16:42:04 Enteral nutritional therapy for individual 21 years of age and older -- Prior authorization required.
67:16:42:04. Enteral nutritional therapy for individual 21
years of age and older -- Prior authorization required. The department must
authorize the use of enteral nutritional therapy for an individual 21 years of
age or older before the service is payable under this chapter. Before
authorization is given, the physician must provide sufficient medical
documentation, including a written order or prescription, to the department
describing the diagnosis and the medical necessity for the therapy.
An authorization may not exceed three
months and a new prescription must be submitted annually. If an initial
authorization or an annual reauthorization is being requested or if there is a
change in the physician's orders, documentation must include the following:
(1) A copy of the
prescription for the needed therapy;
(2) A copy of the
physician's statement giving the reasons the person is unable to receive
adequate nutrition by normal means;
(3) The applicable
procedure codes for the items and services provided;
(4) The provider's usual
and customary charge for the items or services, including formula, durable
medical equipment, and supplies; and
(5) Documentation regarding
other requested routine medical services, such as home health services.
If there is no change in the
physician's orders and a three-month reauthorization is being requested,
documentation need only include the physician's certification that the
individual continues to need the nutritional therapy.
The department may verbally authorize
services when the required information is transmitted to the department. The
department shall verify a verbal authorization in writing following receipt of
the required written documentation.
22 SDR 32, effective September 11, 1995; 35 SDR 49, effective September 10,
Authority: SDCL 28-6-1.
Implemented: SDCL 28-6-1.
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