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

Last reviewed: 2026-09-10

The South Dakota Department of Human Services (DHS) authorizes Physical Therapy services across its CHOICES, Family Support 360, ADLS, and HOPE waivers to address mobility, strength, and fall risk for eligible participants. Providers must first secure an active physical therapy license from the South Dakota Board of Medical and Osteopathic Examiners (SDBMOE) before they can be considered for waiver service authorization.

Approval to bill Medicaid for these services requires dual clearance: professional licensure through SDBMOE and subsequent enrollment through the South Dakota Department of Social Services (DSS) Medicaid Provider Enrollment portal. Out-of-state providers face an additional structural gate, as South Dakota requires a specific service authorization or an existing claim to enroll non-bordering out-of-state servicing locations.

1. Service Definition and Scope

In South Dakota's Medicaid Home and Community-Based Services (HCBS) waivers, Physical Therapy is defined as the evaluation and treatment of a participant to improve or maintain mobility, balance, and physical strength. These services are designed to prevent institutionalization by mitigating fall risks and enhancing independent movement in the community.

Services must be ordered by a physician and fall outside the scope of standard Medicaid state plan benefits. Treatment plans are integrated into the participant's individualized service plan (ISP) managed by their DHS waiver case manager.

2. Regulatory and Oversight Agencies

Physical therapy providers in South Dakota are regulated by a combination of professional licensing boards and state Medicaid agencies. The South Dakota Board of Medical and Osteopathic Examiners handles the clinical licensure of the therapist.

The Department of Social Services (DSS) manages the financial and enrollment aspects of Medicaid, while the Department of Human Services (DHS) oversees the actual waiver programs and HCBS compliance.

3. Gatekeeping Prerequisites: Who Can Even Apply

South Dakota does not require a Certificate of Need for independent physical therapy practices. However, to provide services under HCBS waivers, the applicant must hold an active, unencumbered Physical Therapist license issued by the SDBMOE.

Out-of-state providers face a strict geographic gate: South Dakota Medicaid does not enroll out-of-state providers (located more than 50 miles from the border) unless the service is unavailable in-state and a specific service authorization or claim is already attached to the application.

4. Licensure and Certification Requirements

Physical therapists must meet the statutory requirements set forth in South Dakota Codified Laws (SDCL) Chapter 36-10. This includes graduating from a CAPTE-accredited physical therapy program and passing the National Physical Therapy Examination (NPTE).

Once licensed, therapists must maintain their credentials through continuing education and periodic renewals with the SDBMOE to remain eligible for Medicaid enrollment.

5. Medicaid Provider Enrollment

Enrollment is conducted entirely online through the DSS Medicaid Provider Enrollment portal. South Dakota does not charge an application fee for Medicaid provider enrollment.

Providers must register for a portal account, which is separate from the Medicaid claims portal login, and submit their NPI, taxonomy codes, and licensure details. The system generates a PE System ID upon successful enrollment.

6. Staffing, Training and Background Checks

All personnel providing direct waiver services must pass comprehensive background checks mandated by DHS and DSS. This ensures the safety of vulnerable adults and children receiving HCBS.

In addition to clinical training, waiver providers must complete state-mandated training on abuse, neglect, and exploitation reporting, as well as HCBS Settings Rule compliance.

7. Documentation, Policies and Records

Providers must maintain clinical and financial records that justify the services billed to South Dakota Medicaid. Documentation must align with the participant's ISP and demonstrate progress or maintenance of the participant's physical condition.

Records must be retained for a minimum of six years and be available for audit by DSS, DHS, or federal CMS reviewers upon request.

8. Billing, Rates and Claims

Claims are submitted to the DSS Provider Online Portal using standard HIPAA-compliant formats (837P for professional services). Providers must use the appropriate CPT codes for physical therapy evaluations and therapeutic procedures.

Rates are established by the South Dakota legislature and published on the DSS fee schedules. Waiver services must be prior-authorized, and claims exceeding the authorized units will be denied.

9. Approval Sequence and Timeline

The approval process begins with obtaining the professional license from SDBMOE, which can take 4 to 8 weeks depending on application completeness and background check processing.

Once licensed, the Medicaid enrollment through the DSS portal typically takes 30 to 60 days. Providers cannot bill for services provided prior to their official Medicaid effective date.

10. Common Denials and Survey Findings

Medicaid enrollment applications are frequently delayed or denied due to mismatched information between the IRS, NPPES (NPI registry), and the DSS application. Exact legal name matches are critical.

During post-payment audits, the most common recoupment findings involve missing physician orders, lack of prior authorization, or session notes that fail to document the specific start and stop times of the therapy.

11. Key Contacts and Resources

Providers should utilize the official state portals and contact emails for the most accurate and timely assistance. The DSS Provider Enrollment team handles all MMIS registration issues.

For waiver-specific questions, providers should contact the DHS division responsible for the specific waiver (e.g., Division of Developmental Disabilities for CHOICES and Family Support 360).

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