South Dakota Medicaid's PA-100 is the general prior authorization request for elective services on the Division of Medical Services' prior authorization list, and the Division also uses it for certain surgical and other outpatient services. A clinician meets it when scheduling a listed service that has no dedicated form. It must be sent with medical records supporting the service, and the determination goes to the named point of contact.
The requesting or rendering provider completes the form, including the explanation of problem and prognosis, referring and servicing provider NPIs and taxonomy codes, and a point of contact. The point of contact is the person completing the request.
Download the current version from the source each time; forms change without notice.
Prior Authorization Request Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The Division lists PA-100 as its general form, also used for certain surgical and other outpatient services. Listed surgical procedures include bariatric surgery, breast reconstruction or reduction, cochlear implants, nerve stimulators, spinal procedures and transplants. Separate forms cover DME and nutrition, ABA, Synagis, private duty nursing, out-of-state care, genetic testing and BRCA testing.
The form asks for an explanation of the particular problem resulting from the diagnosis that relates to the request, and how long the problem is expected to last in months, or whether that is unknown or permanent. Medical records supporting the explanation must accompany the form.