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This version of the form is not currently in use and is provided for reference only. Download this version of
Form PA-104
for the current year.
Form PA-104 Private Duty Nursing / Extended Home Health Aide Prior Authorization Request Form - South Dakota
What Is Form PA-104?
This is a legal form that was released by the South Dakota Department of Social Services - a government authority operating within South Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is the Form PA-104?
A: The Form PA-104 is a Prior Authorization Request Form for Private Duty Nursing/Extended Home Health Aide services in South Dakota.
Q: What is Private Duty Nursing?
A: Private Duty Nursing refers to skilled nursing care provided in a patient's home by a licensed nurse.
Q: What are Extended Home Health Aide services?
A: Extended Home Health Aide services are non-skilled personal care services provided in a patient's home by a trained aide.
Q: Why is a Prior Authorization Request Form needed?
A: A Prior Authorization Request Form is needed to obtain approval from the insurance company or Medicaid for Private Duty Nursing/Extended Home Health Aide services.
Q: Who should complete the Form PA-104?
A: The Form PA-104 should be completed by the healthcare provider or agency requesting Private Duty Nursing/Extended Home Health Aide services.
Q: What information is required on the Form PA-104?
A: The Form PA-104 requires information such as patient demographics, diagnosis, requested services, and supporting documentation.
Q: How long does it take to process a Prior Authorization Request?
A: The processing time for a Prior Authorization Request can vary, but it is typically within a few days to a week.
Q: What happens after a Prior Authorization Request is approved?
A: After approval, the patient can receive Private Duty Nursing/Extended Home Health Aide services as prescribed by the healthcare provider.
Form Details:
- Released on December 1, 2022;
- The latest edition provided by the South Dakota Department of Social Services;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form PA-104 by clicking the link below or browse more documents and templates provided by the South Dakota Department of Social Services.
Download Form PA-104 Private Duty Nursing / Extended Home Health Aide Prior Authorization Request Form - South Dakota
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