What types of policy changes does South Dakota Medicaid issue?

South Dakota Medicaid regularly publishes coverage updates including prior authorization requirement changes, billing code additions or deletions, plan-type coverage modifications, and clinical policy revisions. PolicyChanges.app monitors these notices and summarizes the impact for providers.

How often does South Dakota Medicaid update its policies?

South Dakota Medicaid typically releases policy bulletins on a rolling basis throughout the year. Our system checks for new updates daily and adds them to this feed as soon as they are identified.

How many South Dakota Medicaid policy changes are tracked here?

This page currently tracks 23 documented South Dakota Medicaid policy changes. New items are added as they are identified.

What should I do when South Dakota Medicaid changes a prior authorization policy?

Review each change's effective date and action-required notes. Update your billing and clinical workflows before the effective date to avoid claim denials. Each policy detail page on PolicyChanges.app includes a plain-English summary and action items.

South Dakota Medicaid Policy Changes & Prior Auth Updates

We track 23 documented policy changes from South Dakota Medicaid across SD. Each entry includes an AI-generated plain-English summary, effective date, affected billing codes, and a direct link to the original South Dakota Medicaid notice. Use the related links below to narrow results by specialty or state, or sign up for a free daily alert to receive new South Dakota Medicaid updates automatically.

High impact
CPT Code 92507 Billing Update Effective July 1 2025
South Dakota Medicaid·Effective Jul 1, 2025
South Dakota Medicaid is changing CPT code 92507 from a 15-minute time-based billing to a per-session billing model effective July 1, 2025. Providers can only bill one unit per member per day regardless of session length, with the new reimbursement rate set at $67.00 per session.
High impact
Private Duty Nursing Members Providing Care
South Dakota Medicaid·Effective May 9, 2025
South Dakota Medicaid is prohibiting immediate family members or household members from providing Private Duty Nursing services to recipients, based on EVV data review showing violations of existing regulations. Agencies have 30 days to make alternative staffing arrangements for affected cases.
Medium impact
Spring Provider Newsletter
South Dakota Medicaid·Effective May 15, 2026
South Dakota Medicaid is implementing a new biosimilar preferred drug list for physician-administered drugs effective May 15, 2026, and updating hospital reimbursement methodologies from MS-DRG to APR-DRG effective July 1, 2026. Providers must also ensure their enrollment information is current as the state transitions to a new credentialing system.
Medium impact
Physician Administered Drug Biosimilar PDL
South Dakota Medicaid·Effective May 15, 2026
South Dakota Medicaid is implementing a new Preferred Drug List (PDL) for physician-administered biosimilar drugs, requiring prior authorization for non-preferred agents with a 90-day trial of preferred drugs first. The policy rolls out in phases: tocilizumab (May 15, 2026), infliximab (June 15, 2026), and pegfilgrastim (July 15, 2026).
Medium impact
Esketamine Billing Instructions
South Dakota Medicaid·Effective Jan 1, 2026
South Dakota Medicaid is changing the HCPCS code for Esketamine (Spravato) nasal spray billing from S0013 to J0013 effective January 1, 2026. The policy clarifies specific E/M codes and add-on codes for associated professional services and observation time.
Medium impact
Fall Provider Newsletter
South Dakota Medicaid·Effective Jan 1, 2026
South Dakota Medicaid is implementing major federal changes including work requirements for expanded Medicaid, reduced retroactive coverage periods, and more frequent eligibility checks. Hospital reimbursement methodologies will also be updated in 2026, and the Health Home program is being renamed to Care Connect.
Medium impact
School Based Medicaid Program Updates
South Dakota Medicaid·Effective Oct 1, 2025
South Dakota Medicaid is updating its School-Based Medicaid program to comply with CMS regulations, including removal of non-sampled staff costs, updated RMTS requirements, new quarterly sampling periods, and mandatory annual Cost Settlement for schools submitting Direct Service claims. A new TM modifier will be required for services provided under 504 plans or other non-IEP/non-IFSP plans of care.
Medium impact
Evaluation and Management Audio-Only Billing Updates
South Dakota Medicaid·Effective Jul 1, 2025
South Dakota Medicaid is replacing discontinued telephone consultation codes (98966-98968) with new audio-only E/M codes (98012-98015) for established patient visits. The new codes have specific time and medical decision-making requirements with updated reimbursement rates.
Medium impact
Medicaid Reimbursement and Care Management Referral Updates
South Dakota Medicaid·Effective Jul 1, 2025
South Dakota Medicaid implemented a 1.25% rate increase for most services effective July 1, 2025, with targeted increases for specific transportation and physician codes. Additionally, care management referrals are no longer required for outpatient mental health services as of June 1, 2025.
Medium impact
Summer Provider Newsletter
South Dakota Medicaid·Effective Jun 1, 2025
South Dakota Medicaid implemented multiple policy changes effective June 1 and July 1, 2025, including elimination of care management referrals for outpatient mental health services, inflationary rate increases up to 1.25% for services below target methodology, and expanded BabyReady program eligibility to 32 weeks gestation or less.
Medium impact
Urgent Care Visit Billing Instructions
South Dakota Medicaid·Effective May 28, 2025
South Dakota Medicaid allows up to 4 urgent care visits per plan year (July 1 - June 30) without requiring referrals from care management providers. Specific billing instructions must be followed to ensure these visits are properly exempted from referral requirements.
Medium impact
Medicaid Coverage of Limited Services for Incarcerated Juveniles
South Dakota Medicaid·Effective Jan 1, 2025
Effective January 1, 2025, South Dakota Medicaid now covers limited services (targeted case management, screenings, diagnostics, and immunizations) for incarcerated juveniles within 30 days of release post-adjudication. Services must be billed with place of service code 09 and secondary diagnosis Z65.1.
Medium impact
Winter Provider Newsletter
South Dakota Medicaid·Effective Jan 1, 2025
South Dakota Medicaid implemented coverage for doula services and justice involved youth case management effective January 1, 2025. The policy also includes billing reminders for FQHC/RHC providers to use TH modifier for prenatal care and specific codes for postpartum visits and high index lenses.
Medium impact
Immediate Family Members of the Household Providing Care
South Dakota Medicaid·Identified Jun 21, 2026
South Dakota Medicaid is extending the deadline by 6 months for Private Duty Nursing agencies to make alternative staffing arrangements when immediate family members can no longer provide paid caregiving services. The state is also exploring a waiver/exceptions process for extraordinary circumstances where no alternative care options exist.
Medium impact
Winter Provider Newsletter
South Dakota Medicaid·Identified Jun 21, 2026
South Dakota Medicaid released their Winter 2026 Provider Newsletter with key updates including new fee schedules for multiple provider types, Medicare enrollment requirements for dual-eligible recipients, and enhanced eligibility verification processes. The newsletter also announces upcoming grant funding opportunities and program results.
Medium impact
Care Connect Program
South Dakota Medicaid·Identified Jun 21, 2026
The Care Connect Program (formerly Health Home program) offers enhanced reimbursement and quality incentive payments to providers who enroll to provide care coordination services for Medicaid recipients with chronic conditions. This is a voluntary program that requires enrollment and coordination of comprehensive care including physical and behavioral health services.
Medium impact
School District
South Dakota Medicaid·Identified Jun 21, 2026
South Dakota Medicaid issued updated billing reminders for school district and Birth to Three providers, emphasizing monthly eligibility verification, proper use of therapy assistant modifiers (HM, CO, CQ), and the TM modifier requirement for non-IEP/IFSP services that began October 1, 2025.
Medium impact
Primary Care Provider Program
South Dakota Medicaid·Identified Jun 21, 2026
This policy update outlines the Primary Care Provider (PCP) program requirements for Medicaid providers, emphasizing comprehensive primary care services and 24/7 access to information. The policy also announces the upcoming Primary Accountable Care Transformation (PACT) initiative that will evolve Medicaid's primary care approach in 2026-2027.
Medium impact
BabyReady Program
South Dakota Medicaid·Identified Jun 21, 2026
The BabyReady Program is a South Dakota Medicaid care coordination program for pregnant recipients that provides enhanced prenatal and postpartum care coordination. Providers participating in this program are responsible for routine prenatal/postpartum care and implementing initiatives to address care barriers like food insecurity and transportation.
Low impact
Cost Reporting
South Dakota Medicaid·Effective Mar 31, 2026
South Dakota requires out-of-state Psychiatric Residential Treatment Facility (PRTF) providers seeking cost-based reimbursement to submit either a CMS-2552-10 Medicare Cost Report or a Simplified PRTF Cost Report Template by March 31st. Failure to submit will result in default to alternative reimbursement methodologies.
Low impact
PCP Scorecard
South Dakota Medicaid·Effective Sep 1, 2025
South Dakota Medicaid will email Primary Care Provider Scorecards to PCP clinics in September 2025, evaluating clinic performance on preventative care, emergency department visits, and screening measures for calendar year 2024. This is an informational tool to help clinics improve quality of care for Medicaid recipients.
Low impact
Provider Tools
South Dakota Medicaid·Identified Jun 21, 2026
South Dakota Medicaid has updated their provider tools documentation, outlining available resources including the provider portal for eligibility checks and claims submission, provider manuals, fee schedules, and procedure/diagnosis code lookup tools. All tools are accessible at dss.sd.gov/medicaid/providers.
Low impact
Medicaid Benefit Basics
South Dakota Medicaid·Identified Jun 21, 2026
This is an informational overview of Medicaid benefit basics covering medical, dental, vision, transportation, and long-term care services. The policy outlines standard Medicaid coverage categories and references Care Management programs that may require provider referrals for certain services.

South Dakota Medicaid in SD South Dakota Medicaid: Cardiology South Dakota Medicaid: Dermatology South Dakota Medicaid: Emergency Medicine South Dakota Medicaid: Endocrinology All payers

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CPT Code 92507 Billing Update Effective July 1 2025

Private Duty Nursing Members Providing Care

Spring Provider Newsletter

Physician Administered Drug Biosimilar PDL

Esketamine Billing Instructions

Fall Provider Newsletter

School Based Medicaid Program Updates

Evaluation and Management Audio-Only Billing Updates

Medicaid Reimbursement and Care Management Referral Updates

Summer Provider Newsletter

Urgent Care Visit Billing Instructions

Medicaid Coverage of Limited Services for Incarcerated Juveniles

Winter Provider Newsletter

Immediate Family Members of the Household Providing Care

Winter Provider Newsletter

Care Connect Program

School District

Primary Care Provider Program

BabyReady Program

Cost Reporting

PCP Scorecard

Provider Tools

Medicaid Benefit Basics