S.D. Admin. R. 47:03:09:01

Current through Register Vol. 51, page 71, January 6, 2025

Section 47:03:09:01 - Properly submitted medical bill

A properly submitted medical bill is a request by a provider for payment of health care services that meets the following requirements:

(1) Submitted to the employer according to the applicable reporting and coding standards of the Centers for Medicare and Medicaid Studies, the National Council for Prescription Drug Programs, or the American Dental Association; and

(2) Accompanied by sufficient medical records or reports that the employer can determine the reasonableness and necessity of the treatment provided.

A submission to a self-insured employer, insurer, medical bill reviewer, medical case management plan, third party administrator, claims adjuster, trustee, guarantor, or other entity having a similar association to the employer is considered submission to all such entities simultaneously. The employer may waive the requirements of this section.

S.D. Admin. R. 47:03:09:01

34 SDR 322, effective 6/30/2008.

General Authority: SDCL 62-4-1.2.

Law Implemented: SDCL 62-4-1.1, 62-4-1.2.

Note: The Centers for Medicare and Medicaid Studies publishes its bill processing requirements at www.cms.hhs.gov/QuarterlyProviderUpdates. For pharmacy-related bill processing, information is available at NCPDP, Inc. 4201 North 24^th Street, Suite 365, Phoenix, AZ 85016-6268, (602) 957-9105. For dental bill processing, information is available at www.ada.org, 211 East Chicago Ave., Chicago, IL 60611-2678, (312) 440-2500.