South Dakota - Autism Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The South Dakota Department of Social Services (DSS) covers Applied Behavior Analysis (ABA) under the Medicaid state plan, requiring billing providers to hold active state licensure as a physician, psychologist, or behavior analyst.

Approval requires completing the online application through the Provider Enrollment (PE) Portal and submitting supporting documentation via email within 30 days of data capture. Agencies must enroll a Billing NPI (BNPI) and associate individual Servicing NPIs (SNPIs) for each licensed analyst rendering or supervising care.

1. Service Definition and Scope

South Dakota DSS defines ABA as interventions including Behavior Identification Assessment and adaptive behavior treatment. Services can be delivered face-to-face or via telemedicine.

Technicians may administer specific protocols under the direct supervision of enrolled, licensed professionals, but school district providers are explicitly prohibited from billing these services directly to Medicaid.

• Service Name: Applied Behavior Analysis (ABA)
• Direct Delivery: Administered by a technician under the direction of a physician or qualified healthcare professional (e.g., CPT 97153)
• Assessments: Includes Behavior Identification Assessment (CPT 97151, 97152) to identify the frequency and magnitude of maladaptive behaviors
• Telemedicine: Permitted for ABA services under South Dakota Medicaid guidelines
• Exclusions: ABA services may not be provided by school district providers

2. Regulatory and Oversight Agencies

The primary oversight for Medicaid enrollment, billing, and policy is the South Dakota Department of Social Services (DSS).

Professional licensure is managed by the respective state boards for medical and behavioral health professionals.

• Medicaid Agency: South Dakota Department of Social Services (DSS) [https://dss.sd.gov/](https://dss.sd.gov/)
• Enrollment Portal: Provider Enrollment (PE) Portal [https://app-dss-sw85pc05dmsproviderenroll.azurewebsites.net/Account/Login](https://app-dss-sw85pc05dmsproviderenroll.azurewebsites.net/Account/Login)
• Billing Manuals: DSS Provider Billing Manuals [https://dss.sd.gov/Medicaid/providers/billingmanuals/default.aspx](https://dss.sd.gov/Medicaid/providers/billingmanuals/default.aspx)

3. Gatekeeping Prerequisites: Who Can Even Apply

South Dakota does not impose Certificate of Need (CON), closed network moratoria, or county sponsorship requirements for ABA providers.

The structural precondition to apply is holding an active, unrestricted professional license in South Dakota as a physician, psychologist, or behavior analyst prior to initiating the Medicaid enrollment process.

• Network Status: Open enrollment with no RFP or closed network restrictions
• Certificate of Need: None exists for ABA services in South Dakota
• Licensure Prerequisite: Must hold active SD licensure as a physician, psychologist, or behavior analyst before Medicaid enrollment
• Entity Requirement: Organizational providers must obtain a Type 2 (Organizational) NPI and FEIN tied to the legal business name

4. Licensure and Certification Requirements

South Dakota requires ABA providers to be fully licensed in their respective disciplines to enroll as servicing providers.

Technicians deliver services under the direct supervision of these licensed professionals and do not enroll independently.

• Eligible Provider Types: Physicians, Psychologists, and Behavior analysts
• Out-of-State Providers: Must retroactively enroll and provide a claim for eligible services rendered, or be located within 50 miles of the SD border
• Locum Tenens: Servicing providers acting as locum tenens must enroll in SD Medicaid and be listed on the claim form
• Temporary COVID-19 Licenses: MDs, DOs, PAs, CNPs, and ARNPs practicing under out-of-state licenses due to COVID-19 must specifically note this limitation, with eligibility terminating after the emergency declaration

5. Medicaid Provider Enrollment

All enrollment activities are completed through the SD Medicaid Provider Enrollment (PE) Portal.

Providers must register for portal access using their Billing NPI (BNPI) and submit supporting documents via email to the state.

• Application Fee: No application fee is charged by South Dakota Medicaid
• System of Record: Provider Enrollment (PE) Portal
• Submission Window: Enrollment records and documentation must be completed and received within 30 days of starting data capture
• Document Routing: Supporting documentation must be emailed to [email protected] with the NPI and provider name in the body
• Required Forms: Provider Agreement and Disclosure forms are mandatory for all entities and individuals

6. Staffing, Training and Background Checks

Staffing models rely on a tiered approach where licensed professionals direct the care provided by technicians.

The billing provider is responsible for ensuring all rendering staff meet state qualifications and maintain consistent taxonomy codes.

• Supervision: Technicians administer protocol (CPT 97153) face-to-face under the direction of a physician or other qualified healthcare professional
• Taxonomy Consistency: Individuals associated with multiple entities must use a consistent taxonomy code across all associations
• Group Taxonomy: Collectives of professionals billing for services should select a group taxonomy (193200000X or 193400000X) for the BNPI
• Background Checks: Standard Medicaid provider agreement terms apply regarding exclusion checks

7. Documentation, Policies and Records

Providers must maintain accurate online enrollment records reflecting current business operations and payment details.

Clinical documentation must support the specific CPT codes billed, such as detailed adaptive behavior treatment guidance.

• Financial Documentation: Letter from a financial institution is required to support online payment details for Electronic Funds Transfer (EFT)
• Record Maintenance: Providers are required to maintain their online enrollment records to accurately reflect business operations
• Clinical Records: Family adaptive behavior treatment guidance (CPT 97156) must include specific documentation as outlined in the billing manual
• Telehealth Location: Services provided via telehealth must list the distant site location where the provider is physically located

8. Billing, Rates and Claims

ABA claims are submitted using standard CPT codes at the provider's usual and customary charge.

Payment is limited to the lesser of the billed amount or the South Dakota Medicaid fee schedule.

• Payment Limit: Payment is limited to the lesser of the provider's usual and customary charge or the SD Medicaid rate
• Billing NPI (BNPI): Receives the exact amount Medicaid pays, tied to a FEIN
• Servicing NPI (SNPI): Must be enrolled and listed on the claim; payment is directed to the BNPI
• Timely Filing: Providers should complete enrollment actions at least 45 days prior to timely filing deadlines
• Coding Standards: Uses AMA CPT codes (e.g., 97151, 97152, 97153, 97156)

9. Approval Sequence and Timeline

The enrollment process begins with portal registration and data entry, followed by email submission of required forms.

Reviews are generally processed by DSS in the order they are received.

• Step 1: Obtain appropriate professional licensure and NPIs
• Step 2: Register for the PE Portal using the BNPI (must be done by provider staff, not external credentialers)
• Step 3: Complete data capture in the PE Portal within 30 days
• Step 4: Email supporting documentation (Provider Agreement, Disclosure, EFT letter, license copy) to [email protected]
• Step 5: Await DSS review, which is completed in the order received

10. Common Denials and Survey Findings

Enrollment applications are frequently rejected if the 30-day data capture window expires before all supporting documents are received via email.

Claims denials often stem from NPI mismatches or missing servicing provider enrollments.

• Timeout Rejections: Enrollment is denied/rejected if records and documentation are not completed within 30 days of starting data capture
• Credentialing Errors: Initial portal registration must be done by a provider staff member; external credentialing entities cannot complete this step
• NPI Issues: Claims will deny if all eligible servicing and billing provider NPIs are not actively enrolled with SD Medicaid
• Location Mismatches: Out-of-state providers must ensure the state selected matches the servicing location populated in the Location tab

11. Key Contacts and Resources

The South Dakota Department of Social Services provides dedicated support for the Provider Enrollment Portal and general Medicaid inquiries.

Providers should reference the official ABA billing manual for detailed coding and policy guidelines.

• Provider Enrollment Email: [email protected]
• Provider Enrollment Phone: 866-718-0084
• Online Portal Support Email: [email protected]
• SD Medicaid Provider Enrollment Portal: [https://app-dss-sw85pc05dmsproviderenroll.azurewebsites.net/Account/Login](https://app-dss-sw85pc05dmsproviderenroll.azurewebsites.net/Account/Login)
• ABA Billing Manual: [https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/Applied_Behavioral_Analysis.pdf](https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/Applied_Behavioral_Analysis.pdf)

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