South Dakota Medicaid Provides guidance for Billing a Recipient. Per the South Dakota Medicaid Billing and Policy Manual for Billing and Recipient, SD Medicaid recipients are exempt from cost sharing when receiving CHW services and do not have to pay a co-pay to receive services. This is noted under the section of the manual, “Recipients Exempt from Cost Sharing” as noted in the third bullet point – “individuals residing in a long-term care facility or receiving home and community-based services”.

The DSS SD Medicaid Portal webpage allows a user to access various recipient and provider Billing National Provider Identifier (BNPI) based information. The Portal webpage is updated periodically with User Documents, FAQs, and Portal related announcements from the Medicaid Portal Team.  

In addition to Z-Codes for chronic diseases, pregnancy, substance use disorder, and many other Z-codes related to qualifying conditions for CHW services, SD Medicaid also allows for Social Determinants of Health (SDoH) Z-Codes to be utilized on CMS 1500 Claims. The Medicaid Provider Diagnosis Look-Up Tool lists all possible SDoH Z-Codes that can be included on a CMS 1500 Claim for CHW services, as the Z-Code correlates with the provider’s referral and service plan related to a qualifying condition and/or qualifying barrier. See the CHWSD Guide to Using the Medicaid Provider Diagnosis Look-Up Tool for instructions on navigating the tool.

Click below to view a sample CMS 1500 billing form. This will be helpful to understand as you review the Medicaid Claims instructions.