South Dakota Medicaid's PA-101 requests prior authorization of durable medical equipment and medical nutrition products. Clinicians meet it when ordering equipment on the Division of Medical Services' list, such as continuous glucose monitors, wound vacs, speech-generating devices or specialty mobility devices, or enteral and parenteral nutrition. The supplier submits it with the prescriber's order and medical records supporting the request.
The DME or nutrition provider completes every field, using the prescribing practitioner's diagnosis codes, order and records; the prescriber appears as the referring provider. All fields are required.
Download the current version from the source each time; forms change without notice.
Durable Medical Equipment 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.
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The Division's list includes bone growth stimulators, continuous glucose monitors, continuous passive motion devices, cough stimulating devices, cranial remolding helmets, chest wall oscillation devices, low air loss mattresses, lymphedema pumps, specialty mobility devices, speech-generating devices, wound vacs and incontinence supplies.
The Division has 30 days to make a prior authorization determination and says decisions usually take around two weeks. The notice goes to the point of contact listed on the form, who is the person completing the request and the contact for any questions.