South Dakota SD

SD Medicaid is FFS-only (no comprehensive risk MCO). Prior authorization is centralized within DSS Division of Medical Services and submitted by EMAIL to DSSMedicaidPA@state.sd.us (no Acentra/Kepro UM vendor for medical PA). PA is required ONLY for an enumerated list of elective services on the live PA page (DME items, HCBS waivers, home health, inpatient hospitalization, nutrition, out-of-state services, other outpatient/procedures, physician-administered drugs, surgical procedures). The canonical CRITERIA + submission instructions live in ONE master document: the Prior Authorization Manual (General/Prior_Authorizations.pdf). Per-service criteria detail also lives inside individual provider billing manuals. Per-service PA REQUEST FORMS are numbered PA-100..PA-112 under /formsandpubs/docs/MEDSRVCS/. PHARMACY PA is carved out to OptumRx (since 2017-11-13) at sdm.pharmacy.optum.com; SD Medicaid BIN 601574. state_meta currently says Magellan/Conduent which is STALE. state_meta pinned pa_index (prior-authorization.aspx) returns a DSS error page and pinned pharmacy URL returns 404 - both dead; live replacements found.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: None. Next due: ?. Contracts extended through: None.

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## 1. How SD requires PA South Dakota (SD) requires prior authorization (PA) for a variety of services under its Medicaid program. The requirements are detailed in several provider manuals and supplemental documents, which specify the criteria and documentation needed for approval. For prescription drugs, including insulin and certain vitamins for pregnant women, medical necessity is required but step therapy is not specified. Inpatient hospital stays of 24 hours or more also require PA unless they fall under specific exceptions such as delivery/newborn care or Medicare inpatient-only procedures. Durable Medical Equipment (DME) requires a face-to-face encounter within six months and documentation by a physician or licensed practitioner, with CPT/HCPCS codes required for claims. Physician-administered drugs may need clinical prior authorization if they are on the preferred drug list (PDL). Out-of-state services require PA unless they meet specific exceptions. ## 2. How SD publishes and reports PA South Dakota's Medicaid program uses a centralized portal for prior authorization, which is managed by the Department of Social Services (DSS) Division of Medical Services. The state does not specify an external vendor or portal name in the provided documents, but it indicates that PAs are submitted via email to DSSMedicaidPA@state.sd.us. There is no mention of a publicly accessible dashboard or reporting system for PA outcomes or statistics. The provider manuals and supplemental documents provide guidelines on how to submit requests and what documentation is required, but they do not detail the process for tracking or reporting completed PAs. ## 3. SD's CMS-0057-F and PA-reform compliance posture The findings indicate that South Dakota has a structured approach to prior authorization, with specific requirements outlined in provider manuals and supplemental documents. However, there is no explicit mention of the state's compliance with CMS-0057-F or any other PA reform initiatives. The carve-out details suggest that pharmacy services are handled by an external vendor (OptumRx), while behavioral health (BH) services involve a quasi-carve-out to the state Department of Behavioral Health (DBH). Long-term services and supports (LTSS) are managed through an inter-agency split, but there is no specific information on how this affects PA processes. **WISeR is not applicable to SD** — the CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model applies only to AZ, NJ, OH, OK, TX, and WA. The status of any gold-card law is also unspecified. ## 4. How SD runs its own program South Dakota's Medicaid program operates under a fee-for-service (FFS) model without a comprehensive risk managed care organization (MCO). Prior authorization for services is centralized within the DSS Division of Medical Services, with no external vendors handling medical PA requests except for pharmacy services, which are carved out to OptumRx. The state uses an email-based system for submitting PA requests, and there is no mention of a web portal or electronic submission process. The provider manuals and supplemental documents provide detailed guidelines on the criteria and documentation required for various types of services, but they do not specify how decisions are made or how long it takes to receive approval. ## 5. Patterns, what's notable, and what's missing/uncertain **Patterns:** - Centralized PA process managed by DSS Division of Medical Services. - Specific requirements and documentation guidelines for various types of services. - Pharmacy carve-out handled by OptumRx. - Behavioral health quasi-carve-out to state DBH. **Notable:** - No mention of external vendors or portals for medical PA requests except pharmacy. - Detailed provider manuals and supplemental documents outlining PA criteria and documentation. - Specific exceptions for certain inpatient hospital stays and out-of-state services. **Missing/Uncertain:** - Status of any gold-card law. - Compliance with CMS-0057-F or other PA reform initiatives. - Process for tracking and reporting completed PAs. - Specific details on how decisions are made and turnaround times for PA requests. - Information on the state's MCO procurement cycle (FFS model — comprehensive risk MCO not present).