South Dakota Medicaid covers applied behavior analysis under EPSDT "for children 20 years old or younger with an Autism Spectrum Disorder (ASD) diagnosis from a physician or psychologist." Unlike most states, no managed care plan sits between the agency and the family. The Department of Social Services approves ABA itself, pays the claims, and publishes its own ABA manual and fee schedule. Most recipients are in a care-management program (Primary Care Provider or Health Home), but that program is primary care case management, not a health plan. Its practical effect on ABA is that the child’s assigned primary care provider must write the order.
For an agency entering the South Dakota Medicaid market, four facts matter up front. Every billing and servicing behavior analyst must be enrolled with South Dakota Medicaid and licensed by the state. BCaBAs and RBTs cannot enroll and bill only under their supervisor. The diagnosis must be less than 12 months old when services start. Treatment authorizations run 6 months at a time.
The ABA chapter of the South Dakota Medicaid Billing and Policy Manual (updated December 2025) places ABA under EPSDT. It is covered for full-coverage Medicaid and CHIP recipients 20 or younger with an ASD diagnosis from a physician or psychologist. Services "must be ordered by a physician, nurse practitioner, or physician assistant." If the child is in a care-management program, "the ordering provider must be their Care Management provider." The diagnosis "must be within 12 months prior to the start of services." Services must be prior authorized by South Dakota Medicaid before they start. Authorizations "are for a period of 6 months," and a reauthorization is needed after that. The covered services are the assessment (97151, 97152), adaptive behavior treatment by protocol (97153, group 97154), treatment with protocol modification (97155), family guidance (97156, multiple-family 97157) and social-skills groups (97158).[1][2][11][10][12]
There is no Medicaid MCO to contract with. DSS decides prior authorizations, pays claims and handles reconsiderations through its own Medicaid Portal. The care-management layer is the Primary Care Provider Program, "based on the primary care case management (PCCM) model," which about 80% of recipients must join, alongside the Health Home program. A PCP is paid a monthly case-management fee and must authorize most specialty care. Check the portal’s Primary Care Provider/Health Home section before intake so you know whose order to get.[1][2][11][10][12]
Requests go to South Dakota Medicaid by secure email (DSSMedicaidPA@state.sd.us), or by mail or fax (605-773-5246) to the Division of Medical Services in Pierre. The initial assessment and each reassessment must include: the ABA Services Prior Authorization Form; medical records showing an ASD diagnosis within the previous 12 months by a physician or psychologist, naming the evidence-based diagnostic instrument (the manual’s examples are the Gilliam Autism Rating Scale, third edition, ADOS-2 and the Adaptive Behavior Assessment System) with a copy of it; the criteria and frequency for measuring progress; the recommended weekly amount of each service code; the expected duration; a discharge plan if treatment should end within six months of the reauthorization; and, at reassessment, a certification that continued ABA is medically necessary. The behavior treatment plan must be person-centered, with behaviorally defined long-, intermediate- and short-term goals, the schedule and the individual providers responsible, care coordination with school and family, and parent or caregiver training.[1][2][16]
Timing: the PA manual says the agency "has 30 days to make a prior authorization determination," though most take "around 2 weeks." Federal rules have tightened this. Since January 1, 2026 a state Medicaid agency must decide a standard request "in no case later than 7 calendar days" (extendable by 14) and an expedited one within 72 hours. Denial letters give the family 30 days to appeal, and the provider can always resubmit with new records.[1][2][16]
South Dakota publishes its ABA rates as a Power BI report rather than a PDF. The current state-fiscal-year schedule lists, per 15-minute unit: 97151 $35.63, 97152 $21.73, 97153 $21.73, 97154 $5.44, 97155 $39.00, 97156 $22.44, 97157 $13.01 and 97158 $13.01. Every rate shows an update date of 7/1/2026 except 97156 (7/1/2025). 0362T and 0373T are not on the schedule. Claims are billed at your usual and customary charge, and payment is "the lesser of the provider’s usual and customary charge or the fee contained on South Dakota Medicaid’s Applied Behavior Analysis fee schedule."[3][4][1]
Timely filing: South Dakota Medicaid "must receive a provider’s completed claim form within 6 months following the month the services were provided" (ARSD 67:16:35:04). A claim for May services is due by the end of November. Exceptions include claims filed within 3 months of a denial and claims filed with the primary insurer’s EOB within 6 months of its payment or denial. Claims go on a CMS-1500 or 837P. The ordering provider goes in block 17 with the NPI in 17b, and the prior authorization number goes in block 23. Services by a BCaBA or RBT "must be billed under the supervising, licensed, and enrolled behavior analyst" and only with the technician codes 97152–97154. Every servicing and billing NPI must be enrolled.[6][1][12][8]
Appeals: claim reconsiderations go through the Medicaid Portal, generally within 6 months of the date of service or 3 months of the denial remittance, and DSS answers "within 30 days of receipt." A provider can then request a fair hearing from the Office of Administrative Hearings within 30 days of the decision, and corporations must be represented by an attorney. EVV: South Dakota’s EVV manual applies EVV to personal care, home health, private duty nursing and certain waiver codes only. No ABA code is on its lists. The state publishes no clean-claim payment deadline for Medicaid; remittance advices post on the Medicaid Portal.[6][1][12][8]
Corrections: the General Claim Guidance chapter also extends the 6-month limit when "The claim is an adjustment or void of a previously paid claim and is received within 3 months after the previously paid claim." For payment, it asks providers to follow up 30 days after filing if nothing appears on the Provider Remittance Advice (Claims Advice and Processing, 1-800-452-7691); remittance advices are on the Medicaid Portal. The chapter publishes no payment-cycle day or submission cut-off.[6][1][12][8]
ABA may be billed only by licensed and enrolled physicians, psychologists and behavior analysts. South Dakota licenses behavior analysts through the Board of Social Work Examiners (SDCL 36-38), so a BCBA billing South Dakota Medicaid needs the state license as well as Medicaid enrollment. BCaBAs and RBTs "are not eligible to enroll"; they deliver services under a licensed, enrolled behavior analyst. ABA may be delivered by real-time telemedicine, but the BCBA "must have an in-person face-to-face visit within the first 30 days and every 90 days thereafter." The distant-site practitioner "must be licensed to provide the service in both the state of the originating site and state of the distant site," and the distant site must be listed on the provider’s enrollment record. Out-of-state providers otherwise need prior authorization for most services. That out-of-state PA does not apply to telemedicine when the child is in South Dakota, but the ABA PA still does.[1][5][9][13][14][19][20]
Can a BCBA licensed in another state treat a South Dakota child? Generally not without a South Dakota license. SDCL 36-38-6 requires the state license to practice ABA here. The only exemption for out-of-state analysts is narrow: a provider "who is not a resident of this state, and who has established an office in this state," authorized in their home state, may practice for no more than an aggregate of 20 days a year, and must report to the board once past 20 consecutive days (36-38-5(2)). Telehealth does not get around this. SDCL 34-52-2 says any health care professional "treating a patient in the state through telehealth" must be "fully licensed to practice in the state" or employed by one of the listed facility types (a licensed health care facility, accredited prevention or treatment facility, community support provider, nonprofit mental health center, or licensed child welfare agency). The carriers say the same thing: Aetna tells providers to "ensure that they have the proper licensure based on state requirements," and Aetna’s ABA guide requires billing by "licensed behavior analysts (in states with behavior analyst licensure laws)." For a remote BCBA, plan on a South Dakota license before the first session.[1][5][9][13][14][19][20]
The questions that decide whether a family can start with South Dakota Medicaid, and what they have to bring. Each maps onto something intake should ask on the first call.
20 years old or younger (EPSDT).[1]
The diagnosis "must be within 12 months prior to the start of services," and each PA request needs medical records showing an ASD diagnosis "within the previous 12 months."[1]
A physician or a psychologist.[1]
The request must name "the evidence-based diagnosis evaluation instrument" and attach a copy of it. The manual’s examples are the Gilliam Autism Rating Scale (third edition), the Autism Diagnostic Observation Schedule (second edition) and the Adaptive Behavior Assessment System.[1]
Yes. ABA "must be ordered by a physician, nurse practitioner, or physician assistant," and if the child is in a Care Management program (PCP or Health Home) "the ordering provider must be their Care Management provider." DSS’s Referrals manual sets what any referral must carry: recipient name, referred-to provider, services or condition, a time-span "not to exceed one year," the referring provider’s name and NPI, and a date and authorized signature. DSS has no required form: a referral letter, a documented phone referral, a customized form or a certificate of medical necessity all work if they hold that information, and both providers keep a copy. The ordering or referring provider goes in CMS-1500 block 17 with the NPI in 17b, and the PA number in block 23. In practice, ask the child’s PCP or Health Home for the order, and renew it before its time-span runs out.[1][10]
Yes. ABA "may be provided via telemedicine" by "real-time" interactive telecommunications, with an in-person BCBA visit within the first 30 days and every 90 days after. Behavior analysts and BCaBAs are on the list of distant-site providers. The child’s home is an eligible originating site. The practitioner must be licensed in both the child’s and the provider’s state, the distant site must be on the provider’s enrollment record, and claims carry modifier GT in the first position with POS 02 or 10. Which ABA codes are allowable by telemedicine is flagged in DSS’s Procedure Code Look-Up Tool. Audio-only ABA is not among the covered audio-only services.[1][5]
The PA manual says DSS "has 30 days to make a prior authorization determination," usually "around 2 weeks." Federal law is stricter for decisions from January 1, 2026: a standard request "in no case later than 7 calendar days" (extendable by up to 14 days) and an expedited one within 72 hours. Treatment authorizations last 6 months, so request reauthorization ahead of the end date.[2][16][1]
South Dakota Medicaid "is generally the payer of last resort." Providers must pursue other coverage first and attach the third-party EOB. Two details matter for ABA. First, the claim manual exempts "services for early and periodic screening, diagnosis, and treatment provided under ARSD § 67:16:11" from billing the other payer first, but that chapter limits its EPSDT services to screenings, orthodontics, private duty nursing, extended home health aide services, nutritional supplements and immunizations (ARSD 67:16:11:03). ABA is not among them, and the ABA manual tells providers to "pursue the availability of third-party payment sources," so bill the child’s other coverage first. Second, if the child’s commercial plan denies because you are out of its network, "Medicaid will still process the claim according to the state plan and reimburse the service if it is covered." A claim filed with the primary’s EOB is timely if it reaches DSS within 6 months of the primary’s payment or denial.[6][1][21][17]
Coverage decides whether South Dakota Medicaid pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Technician services may be provided by a BCaBA or an RBT certified by the BACB "when supervised by a licensed and enrolled behavior analyst." 97155 may be used to bill "case supervision." No numeric supervision ratio is published. For telemedicine, the BCBA must see the child in person within the first 30 days and every 90 days after that. State law also requires each supervised BCaBA or technician to pass a fingerprint background check paid for by the supervising analyst (SDCL 36-38-25).[1][5][13]
The ABA manual sets no unit cap. Hours are set per authorization from the "clinical recommendation of the amount of weekly services necessary by service code." DSS applies NCCI-MUE edits and runs a separate NCCI-MUE reconsideration review for denials.[1][12]
"Each entry in the record must be signed and dated by the individual providing the care including a notation of their credentials or licensure type." When care is given by someone working under the supervision of a participating provider, "the supervising individual must countersign each entry." Time-based codes need start and end times, and services must be documented "at the time they are rendered." Records are kept at least 6 years.[7][1]
"ABA services may not be provided by school district providers. However, an eligible ABA provider may provide services in a school district setting." Not covered: services in "non-conventional" settings such as resorts, spas and camps, provider travel time, transportation, and services that are educational, vocational or recreational. Telemedicine is billed with POS 02 (not the home) or 10 (the home).[1][5]
Billing providers are licensed, enrolled physicians, psychologists and behavior analysts. BCaBA and RBT services "must be billed under the supervising, licensed, and enrolled behavior analyst" and only with 97152–97154. All servicing and billing NPIs must be enrolled. The ordering provider goes in block 17/17b and the PA number in block 23.[1]
Not addressed. The manual says 97155 "May include simultaneous direction of technician," but it does not say whether the technician’s 97153 may be billed for the same minutes.[1]
Blocked on: South Dakota Medicaid Claims Advice and Processing Specialists, 1-800-452-7691, or the Procedure Code Look-Up Tool on dss.sd.gov: ask whether 97153 and 97155 may be billed for the same clock time.
Yes, for children 20 years old or younger with an ASD diagnosis from a physician or psychologist, under EPSDT. It must be ordered by a physician, NP or PA and prior authorized by South Dakota Medicaid.
No. DSS authorizes and pays ABA itself. The PCP and Health Home programs are primary care case management, not health plans, but the child’s assigned PCP or Health Home must write the ABA order.
Yes. The ABA manual says "The ordering or referring provider must be listed in block 17 and their NPI must be listed in 17b," with the prior authorization number in block 23. For a child in the PCP or Health Home program, that provider must be the child’s Care Management provider. An ordering provider who bills nothing can be enrolled through DSS’s streamlined ordering/referring enrollment just by appearing on claims.
No. DSS "does not require providers to use a specific form for referrals." Any written or documented referral works if it has the recipient’s name, the referred-to provider, the services or condition, a time-span of no more than one year, the referring provider’s name and NPI, and a date and signature.
No more than 12 months old at the start of services. The PA request must name the diagnostic instrument (for example ADOS-2 or GARS-3) and include a copy.
Per 15-minute unit (current state fiscal year): 97151 $35.63, 97152 $21.73, 97153 $21.73, 97154 $5.44, 97155 $39.00, 97156 $22.44, 97157 and 97158 $13.01. Payment is the lesser of your charge or the fee schedule.
The claim must be received within 6 months following the month of service (for example, May services by the end of November). Denied claims can be resubmitted within 3 months of the denial.
No. South Dakota’s EVV manual covers personal care, home health, private duty nursing and certain waiver services; no ABA code is listed.
Only with a South Dakota license as well. The Medicaid telemedicine manual requires the practitioner to be licensed in both the child’s state and their own, state law (SDCL 34-52-2) requires full South Dakota licensure to treat a patient in the state by telehealth, and the BCBA must still see the child in person within 30 days and every 90 days.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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