S.D. Admin. R. 20:06:27:01

Current through Register Vol. 50, page 159, June 17, 2024

Section 20:06:27:01 - Definitions

Terms used in this section mean:

(1) "ASC Z12N standard format," the standards for electronic data interchange within the health care industry developed by the Accredited Standards Committee Z12N Insurance Subcommittee of the American National Standards Institute;

(2) "CDT-2 codes," the current dental terminology prescribed by the American Dental Association;

(3) "CPT-4 codes," codes for medical services and procedures performed by medical providers as listed in Physicians Current Procedural Terminology, (CPT '95) Fourth Edition, published by the American Medical Association;

(4) "HCFA," the Health Care Financing Administration of the U.S. Department of Health and Human Services;

(5) "HCFA Form 1450," the health insurance claim form maintained by HCFA for use by institutional care practitioners;

(6) "HCFA Form 1500," the health insurance claim form maintained by HCFA for use by health care practitioners;

(7) "HCPCS," HCFA's common procedure coding system which describes products, supplies, procedures, and health professional services;

(8) "HCPCS Level 1 Codes," the AMA's CPT-4 codes and modifiers for professional services and procedures;

(9) "HCPCS Level 2 Codes," alphanumeric codes and modifiers for health care products and supplies, as well as some codes for professional services not included in the AMA's CPT-4;

(10) "HCPCS Level 3 Codes," local alphanumeric codes and modifiers for items and services not included in the HCPCS Level 1 or HCPCS Level 2;

(11) "Health care practitioner," a provider of health care as follows:

(a) A chiropractor licensed under SDCL chapter 36-5;

(b) A corporation or partnership of health care practitioners listed in this subdivision;

(c) A dentist licensed under SDCL chapter 36-6 A;

(d) A nurse licensed under SDCL chapter 36-9 or 36-9 A;

(e) An optometrist licensed under SDCL chapter 36-7;

(f) A physician licensed under SDCL chapter 36-4;

(g) A podiatrist licensed under SDCL chapter 36-8;

(h) A psychologist licensed under SDCL chapter 36-27 A;

(i) A speech, physical, respiratory, or occupational therapist licensed under SDCL chapter 36-10 or 36-31;

(j) A medical assistant licensed under SDCL chapter 36-9 B;

(k) A physician assistant licensed under SDCL chapter 36-4 A; or

(l) An emergency medical technician licensed under SDCL chapter 36-4 B;

(12) "ICD-9-CM codes," the diagnosis and procedure codes in the International Classification of Diseases, Ninth Revision, Clinical Modification published by the U.S. Department of Health and Human Services;

(13) "Institutional care practitioner," a facility licensed under SDCL chapter 34-12 or listed in §44:04:01:02;

(14) "Issuer," an insurance company, fraternal benefit society, health care service plan, health maintenance organization, third party administrator, and any other entity reimbursing the costs of health care expenses;

(15) "J512 form," the uniform dental claim form approved by the American Dental Association for use by dentists;

(16) "Revenue codes," the codes established for use by institutional care practitioners by the National Uniform Billing Committee.

S.D. Admin. R. 20:06:27:01

22 SDR 97, effective 12/18/1995.

General Authority: SDCL 58-12-14.

Law Implemented: SDCL 58-12-12.