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 use of enteral nutritional therapy for an individual 21 years
of age or older must be authorized by the department before the service is
payable under this chapter. Authorization may only be given if the physician
has provided sufficient medical documentation, including a written order or
prescription, to the department describing the diagnosis and the medical
necessity for the therapy.
Prior authorization and a new prescription are
required 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
(2) A copy of the physician's statement
giving the reasons the person is unable to receive adequate nutrition by normal
(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 an annual reauthorization is being requested, documentation need only
include the physician's certification that the individual continues to need the
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.
Source: 22 SDR 32, effective September 11,
1995; 35 SDR 49, effective September 10, 2008; 40 SDR 122, effective January 7,
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
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