S.D. Admin. R. 67:16:41:10

Current through Register Vol. 51, page 67, December 16, 2024

Section 67:16:41:10 - Noncovered services

The department does not cover and the provider may not submit a claim for:

(1) Mental health services not defined in § 67:16:41:01;

(2) Mental health treatment provided without the recipient physically present in a face-to-face session with the mental health provider, except for telehealth treatment and collateral contact;

(3) Treatment for a mental health disorder not included in the diagnosis codes set forth in § 67:16:41:05;

(4) Mental health treatment provided before a diagnostic assessment is completed, except treatment provided with a provisional diagnosis of a mental health disorder during the thirty day time period the mental health provider has to complete the diagnostic assessment;

(5) Mental health treatment provided after thirty days of intake, if a treatment plan has not been completed;

(6) Mental health treatment provided if a required treatment plan review has not been completed;

(7) Court appearance, staffing sessions, or treatment team appearances;

(8) Mental health services provided to a recipient incarcerated in a correctional facility;

(9) Mental health services provided to a recipient in an institution for mental diseases or an intermediate care facility for individuals with intellectual disabilities;

(10) Mental health treatment provided, if the treatment does not demonstrate a reasonably-timed continuum of progress toward the specific goals stated in the treatment plan, as determined by the peer review entity;

(11) Mental health treatment provided, if the treatment is not listed in the treatment plan or documented in the recipient's clinical record, even though the service is allowable under this chapter;

(12) Mental health treatment provided to a recipient who is:

(a) Incapable of cognitive functioning due to age or mental incapacity; or

(b) Unable to receive any benefit from the service;

(13) Mental health services performed without relationship to evaluations or psychotherapy for a specific condition, symptom, or complaint;

(14) Time spent preparing reports, treatment plans, or clinical records outside the scope of covered procedure codes;

(15) A service designed to assist a recipient regulate a bodily function controlled by the autonomic nervous system, by using an instrument to monitor the function and signal the changes in the function;

(16) Alcohol or drug rehabilitation therapy;

(17) Missed or canceled appointments;

(18) Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family members or another responsible person;

(19) Medical hypnotherapy;

(20) Field trips and other off-site activities;

(21) Consultations or meetings between an employer and employee;

(22) Review of work product by the treating mental health provider;

(23) Telephone consultations with or on behalf of the recipient, except for collateral contact;

(24) Educational, vocational, socialization, or recreational services, or components of services, including:

(a) Activity group therapy;

(b) Assertiveness training;

(c) Bioenergetics therapy;

(d) Consciousness training;

(e) Dance therapy;

(f) Day care;

(g) Educational activities;

(h) Family counseling;

(i) Growth groups or marathons, and psychotherapy for nonspecific conditions of distress;

(j) Guided imagery;

(k) Marital counseling;

(l) Marriage enrichment;

(m) Milieu therapy;

(n) Music therapy;

(o) Obesity control therapy;

(p) Occupational therapy;

(q) Parental counseling or bonding;

(r) Peer relations therapy;

(s) Play observation;

(t) Primal scream therapy;

(u) Recorded psychotherapy;

(v) Recreational therapy;

(w) Religious counseling;

(x) Rolfing or structural integration;

(y) Sensitivity training;

(z) Sex therapy;

(aa) Sleep observation;

(bb) Tape therapy;

(cc) Training disability service;

(dd) Vocational counseling;

(ee) Z-therapy; and

(25) Mental health treatment delivered in excess of the prescribed frequency, as outlined in the treatment plan.

S.D. Admin. R. 67:16:41:10

22 SDR 6, effective 7/26/1995; 26 SDR 168, effective 7/1/2000; 37 SDR 53, effective 9/23/2010; 40 SDR 122, effective 1/8/2014; 45 SDR 082, effective 12/10/2018; 46 SDR 050, effective 10/10/2019; 48 SDR 39, effective 10/3/2021; 49 SDR 021, effective 9/12/2022; 50 SDR 063, effective 11/27/2023

General Authority: SDCL 28-6-1.

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