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    v1.0.28
    OpenPayerPolicy UpdatesPediatrics/NeonatologySouth Dakota Child Advocacy Policy | OpenPayer
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    CurrentSouth Dakota Department of Social ServicesPolicy N/A

    Child Advocacy Program

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    This policy governs coverage, provider eligibility, billing, documentation, and reimbursement for medically necessary services provided to South Dakota Medicaid-eligible children age 18 or younger who may have been victims of child maltreatment. Covered services include forensic interviews, specified office visits, and medically necessary related ancillary services when program requirements are met.

    Policy Summary
    PayerSouth Dakota Department of Social Services
    PolicyChild Advocacy Program
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionVerify the recipient's Medicaid eligibility before providing services using the Medicaid ID card or South Dakota Medicaid's online portal.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    18 or youngerMaximum eligible recipient age
    6 months

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Initial claim filing deadline
    6 yearsRecord retention period
    Q4Required modifier
    4Covered service categories
    3 monthsReconsideration deadline after denial

    Program Coverage Criteria

    Initial program eligibility and coverage

    Covered services require all applicable program and general coverage requirements.

    Program eligibility and coverage

    • Recipient requirements

      • The recipient has Medicaid/CHIP full coverage and is age 18 or younger.18 or younger

    • Referral requirement

      • The provider has a referral from law enforcement or the Office of Child Protection.

        If a referral was not recorded, South Dakota Medicaid may seek recovery of the payment.

    • General coverage requirements

      • The provider is properly enrolled; the service is medically necessary; the recipient is eligible; and, if applicable, the service is prior authorized.

    • Covered program service

      • The service is one of the covered Child Advocacy Program services.

    Covered service categories

    Covered service categories include the following.

    Covered service type

    • Forensic interview

      • Forensic interview billed with CPT 99499.CPT 99499

    • Established-patient office visit

      • Established-patient office visit billed with CPT 99212, 99213, 99214, or 99215.CPT 99212, 99213, 99214, or 99215

    • Not-established-patient office visit

      • Not-established-patient office visit billed with CPT 99215, 99203, 99204, or 99205.

    Services not listed in the Child Advocacy Program covered services table are non-covered.

    Coding and Billing Parameters

    Covered CPT Codes - Forensic InterviewCPTCovered
    99499Forensic Interview
    Covered CPT Codes - Office Visit, EstablishedCPTCovered
    99212Office Visit - Established
    99213Office Visit - Established
    99214Office Visit - Established
    99215Office Visit - Established
    Covered CPT Codes - Office Visit, Not EstablishedCPTCovered
    99215Office Visit - Not Established
    99203Office Visit - Not Established
    99204Office Visit - Not Established
    99205Office Visit - Not Established
    Covered Services - Related Ancillary ServicesmixedCovered
    VariousMedically necessary related ancillary services
    Required ModifierModifier
    Q4Modifier required for services meeting Child Advocacy Program requirements
    Recipient age
    Eligible recipient age18 or younger
    Initial claim filing
    Initial claim filing deadlineWithin 6 months of the date of service
    Reconsideration filing
    Reconsideration filing limitWithin 6 months of the date of service or within 3 months of the date a claim was denied

    Provider Responsibilities and Denial Risks

    Documentation Required

    Maintain Complete Records

    Keep legible medical and financial records that fully justify and disclose the extent of services provided and billed to South Dakota Medicaid. Retain these records for at least 6 years after the last date a claim was paid or denied.

    • Records must support the services provided and billed.
    • No portion of the records is exempt from a record request.
    • Refer to the Documentation and Record Keeping manual for additional requirements.
    Documentation Required

    Document the Program Referral and Services

    Retain documentation in the medical record showing the qualifying Child Advocacy Program referral and supporting the services billed and individuals who rendered them. Records must be available for audit and tracking and may be requested to demonstrate that program requirements were met.

    • Document an appropriate referral from law enforcement or the South Dakota Division of Child Protection Services.

    Child Advocacy Program Overview

    The Child Advocacy Program provides medically necessary evaluation and treatment services for South Dakota Medicaid-eligible children age 18 or younger who may have experienced neglect, physical abuse, sexual abuse, or emotional abuse. Covered services may include forensic interviews, office visits, and medically necessary related ancillary services. The program was previously known as Child's Voice.

    Policy Summary
    PayerSouth Dakota Department of Social Services
    PolicyChild Advocacy Program
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionVerify the recipient's Medicaid eligibility before providing services using the Medicaid ID card or South Dakota Medicaid's online portal.
    SourceLink
    On This Page
    Program Coverage CriteriaCoding and Billing ParametersProvider Responsibilities and Denial RisksChild Advocacy Program Overview
    CPT 99215, 99203, 99204, or 99205

  1. Related ancillary services

    • Medically necessary related ancillary services.Various
    2. Record retention
    Record retention periodAt least 6 years after the last date a claim was paid or denied
  2. Keep notes supporting the HCPCS billed and the individuals rendering services.

    3. Unsupported block type: billing_rule

    Denial Risk

    Missing Qualifying Referral

    A qualifying referral from law enforcement or the Office of Child Protection is required. If the referral was not recorded, South Dakota Medicaid may seek recovery of the payment.

    • Ensure the referral is documented in the medical record before billing.
    • A missing referral record creates a payment-recovery risk.
    Denial Risk

    Unlisted Services Are Non-Covered

    Bill only services listed as covered under the Child Advocacy Program for recipients who meet the applicable eligibility requirements. Services not listed in the covered-services table are non-covered.

    • Covered services include forensic interview (CPT 99499), established office visits (CPT 99212–99215), new-patient office visits (CPT 99203–99205), and medically necessary related ancillary services.
    • A forensic interview is reimbursable in addition to the office visit.
    Denial Risk

    Meet General Coverage Requirements

    To receive payment, providers must satisfy South Dakota Medicaid’s general coverage requirements. Failure to meet enrollment, medical-necessity, recipient-eligibility, or applicable authorization requirements may result in denial or unavailable payment.

    • All servicing and billing providers’ NPIs must be enrolled with South Dakota Medicaid; locum tenens servicing providers must also enroll and be listed on the claim.
    • Services must be medically necessary and the recipient must be eligible.
    • Obtain prior authorization when applicable; Child Advocacy Program services are exempt from prior authorization, care management referral, and third-party-liability reimbursement requirements.
    • Providers must comply with applicable non-discrimination requirements.
    Billing Rule

    File Claims and Reconsiderations on Time

    Submit a completed claim form within 6 months of the date of service. Reconsideration requests must be received within 6 months of the date of service or within 3 months of the date the claim was denied.

    • The time limit may be waived or extended for an adjustment or void received within 3 months after the previously paid claim.
    • A claim following a retroactive initial eligibility determination resulting from an appeal may be received within 6 months after the determination.
    • A claim may be received within 3 months after a previously denied claim.
    • A claim may be received within 6 months after payment from, or a denial notice from, Medicare or private health insurance.
    • The time limit may be waived or extended to correct an error made by the department.