S.D. Admin. R. 67:16:28:10

Current through Register Vol. 50, page 162, June 24, 2024

Section 67:16:28:10 - Claim requirements

A claim for services provided under this chapter must be submitted on a form which contains the following information:

(1) The recipient's full name;

(2) The recipient's medical assistance identification number from the recipient's medical assistance identification card;

(3) Third-party liability information required under chapter 67:16:26;

(4) Date of service;

(5) Place of service;

(6) The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge;

(7) The applicable procedure codes as contained in either CMS Common Procedure Coding System (HCPCS) or the Physicians' Current Procedural Terminology (CPT) for services covered under § 67:16:28:04;

(8) The units of service furnished, if more than one; and

(9) The provider's name and medical assistance identification number.

A separate claim form must be used for each recipient.

S.D. Admin. R. 67:16:28:10

17 SDR 4, effective 7/16/1990; 17 SDR 22, effective 8/14/1990; 18 SDR 78, effective 11/4/1991; 19 SDR 26, effective 8/23/1992; 19 SDR 165, effective 5/3/1993; 20 SDR 149, effective 3/21/1994; 21 SDR 183, effective 4/30/1995; 34 SDR 68, effective 9/12/2007; 43 SDR 80, effective 12/5/2016

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

Note: The CMS 1500 form substantially meets the requirements of this rule and its content and appearance are acceptable to the department. These forms are available for direct purchase through the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402. (202) 783-3238 - pricing desk.

Claims, ch 67:16:35. Use of CPT, § 67:16:01:25. Use of HCPCS, § 67:16:01:27.