What is prior authorization?
Prior authorization (PA) means the health plan must approve certain care before it will cover it. Providers often submit requests for you, but you still have rights if PA is denied or delayed.
Overview: Prior authorizations. South Dakota-only details below.
Confirm plan type: South Dakota: Start Here.
South Dakota PA rules
South Dakota's core utilization review framework is in SDCL Chapter 58-17H (effective July 1, 2011). Utilization review organizations must register with the Division of Insurance (URO listing).
Key SDCL 58-17H requirements
- Prospective review (prior authorization) before services are provided
- Reviews must use documented clinical criteria and qualified licensed health care professionals
- Emergency services cannot require prior authorization
- Timing and notice requirements for adverse determinations
Step therapy overrides (SB 155, 2021)
Insurers must grant step-therapy overrides when:
- The drug is contraindicated or has failed
- The patient is stable on current treatment
- Standard override requests: decision within 5 days
- Urgent override requests: within 72 hours
- If the insurer misses these deadlines, the override is deemed approved
HB 1199 (2026) — transparency and PA review
House Bill 1199 requires utilization review entities and health carriers to annually review prior authorization use, eliminate PA for services routinely approved without meaningful quality or cost benefit, and report data to the Division of Insurance. This is not a provider gold-carding program with fixed approval-rate thresholds.
Gold carding
South Dakota has not enacted a statewide gold-carding law as of 2026. Some national carriers operate voluntary gold card programs in the state.
Federal CMS timing (many plans, 2026)
Many Marketplace, Medicare Advantage, and Medicaid managed care plans must also follow federal PA rules (72-hour urgent / 7-day standard, denial reasons, and public reporting).
Where to look up PA rules
Check your plan materials and the carrier's member or provider portal first.
Carrier links: South Dakota prior auth & internal appeals links.
Medicaid
South Dakota Medicaid prior authorization follows DSS rules—often about 30 days for elective services; urgent/emergent care is generally exempt. See the Medicaid PA manual.
If PA is denied
Appeal through your plan's internal grievance under SDCL 58-17I, then Division of Insurance external review if the denial is a medical-necessity adverse determination.
Urgent care
Request urgent step-therapy overrides within 72 hours under SB 155. For other urgent PA disputes, use expedited internal grievance and call the Division of Insurance at 605-773-3563 for expedited external review instructions.