2. Hospital Notice SDCL 28-13-34.1 Application for Poor Relief SDCL 28-13-32.3 & 32.4 Residency Requirement SDCL 28-13-3 & 28-14-2.1 Post- Secondary Student SDCL 28-13-27(6)(b) Veteran or Indian Health Services SDCL 28-13-1.3(5) Emergency vs. non-emergency admissions SDCL 28-13-33 Ability to purchase Health Insurance SDCL 28-13-27(c)(d) Hospital must exhaust all avenues of payment SDCL 28-13-33.2 ELIGIBILITY CHECKLIST YES NO

3. Was Hospital Notice Received? Was the Notice Received within 15 days? Does the Notice Contain Name & last known address of patient and responsible party Name of Attending physician Nature & degree of severity of illness Anticipated diagnostic or therapeutic services required Location of services provided Estimated reimbursement for services Statement that hospital asked if Veteran or Indian Health Services Hospital Notice SDCL 28-13-34.1 County Manual 2100 NO YES NO Deny Pursuant to SDCL 28-13-34.1 Proceed to Next Step

4. SDCL 28-13-32.3 & 32.4 Application for Poor Relief County Manual 2300 & 3000 Did Hospital submit application within 1 year from discharge date? Or Did patient request assistance within 2 years from discharge date? Deny SDCL 28-13-32.3 & 28-13-32.4 NO Has the patient made an application? Proceed to next step Application pending- County is unable to determine indigency as defined 28-13-1.3 NO

5. Residency Requirement SDCL 28-13-3 & 28-14-2.1 County Manual 1300 Was applicant resident of county 60 days prior to hospitalization? Was applicant’s prior resident outside state of South Dakota ? Recommended to confer with county of prior residency (refer to SDCL 28-14-2.1) Does applicant have evidence of residence by any of the following ? Personal Presence Fixed and permanent abode(home) Intention to remain Local bank account Driver’s license address in county Automobile registration Enrollment of children in local school Voter registration NO YES 28-13-8 Residency continued until lost by new residency 28-13-14 Residency not established by health care facility Nursing home or assisted living Jails/prisons Halfway houses Other temporary living situations

6. Post- Secondary Student SDCL 28-13-27(6)(b) County Manual 3200 Was applicant post-secondary student at a time of hospitalization ? Proceed to next step Is insurance offered at school (Contact admission or visit https://myhealth.sdbor.edu ) https://myhealth.sdbor.edu Did the student take health insurance offered? Deny SDCL 28-13-1.3(1) NO Proceed to next step Deny SDCL 28-13-27(6)(b) YES

7. Veteran or Indian Health Services SDCL 28-13-1.3(5) County Manual 2410 & 2420, Chapter 6 & 7 Is the individual Native American or a Veteran? Was or is applicant eligible for services with VA or IHS? Did hospital request reimbursement within 72 hours? Proceed to next page Was Request for Payment denied for the following: non-emergency Hospital failed to apply Deny SDCL 28-13- 1.3 NO If Veteran is able to enroll in VA but chosen not to Deny SDCL 28-13-1.3(1) or 28-13-27(6)(b)

8. Emergency vs. non-emergency admissions SDCL 28-13-33 County Manual 2000 and 2600 Was the visit scheduled? Some identifying factors UB02 Admission box 14 coded as 1 or3 Emergency room services listed on bill Medical records Deny SDCL 28-13-33 Were the services pre- approved by the county? YES Do services meet definition of “emergency” as defined in SDCL 28-13-27(2)? The need for emergency care is expected to result in death, additional serious jeopardy to individual’s health. NO Proceed to next page YES SDCL 28-13-37.1 County may request review by Department of Social Services

9. Ability to purchase Health Insurance SDCL 28-13-27(c)(d) County Manual 1700 & 4400 Does applicant have insurance? Is hospitalization for non- covered service that are pre-existing? Does individual have pre- existing condition? Determine ability to pay Determine ability to purchase insurance Proceed to next page NO YES NO

10. SDCL 28-13-33.2 Hospital must exhaust all avenues of payment including accepting reasonable monthly payments County Manual 2400 & 2500, Chapter 8 Does patient state that has ability to make payment? Is payment considered reasonable? See county manual Tab 2500 Has hospital exhausted all avenues? Indian Health Services Veteran Medicaid Medicare Social Security Disability Process ability to pay YES Deny SDCL 28-13-33.2 Hospital must exhaust all avenues of payment including accepting reasonable monthly payment from individual YES