S.D. Admin. R. 67:16:39:13

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

Section 67:16:39:13 - Billing requirements

Claims submitted under this chapter must meet the following requirements:

(1) Physician services must follow the billing requirements contained in chapter 67:16:02;

(2) Inpatient/outpatient hospital services must follow the billing requirements contained in chapter 67:16:03;

(3) Home health services must follow the billing requirements contained in chapter 67:16:05;

(4) Screening services must follow the billing requirements contained in chapter 67:16:11;

(5) Clinic services must follow the billing requirements contained in chapter 67:16:13;

(6) Ambulatory surgical center services must follow the billing requirements contained in chapter 67:16:28;

(7) Medical equipment services must follow the billing requirements contained in chapter 67:16:29;

(8) Organ transplant services must follow the billing requirements contained in chapter 67:16:31;

(9) School district services must follow the billing requirements contained in chapter 67:16:37;

(10) Mental health services provided by independent practitioners must follow the billing requirements contained in chapter 67:16:41;

(11) Federally qualified health center and rural health clinic services must follow the billing requirements contained in chapter 67:16:44;

(12) Diabetes self-management training must follow the billing requirements contained in chapter 67:16:46; and

(13) Chemical dependent and substance abuse treatment services must follow the billing requirements contained in chapter 67:16:48.

A provider may not, on behalf of a recipient, submit a claim for services provided under this chapter unless the provider is the recipient's primary care provider or unless the covered service was provided as a result of a referral and authorization by the recipient's primary care provider.

If a recipient's primary care provider is submitting a claim for covered services, the claim must contain the primary care provider's National Provider Identifier number. If a provider is submitting a claim for covered services provided as a result of a referral and authorization by the recipient's primary care provider, the claim must contain the provider's National Provider Identifier number, as well as the National Provider Identifier number of the recipient's primary care provider.

A claim submitted without the required National Provider Identifier (NPI) number is cause for denial by the department.

S.D. Admin. R. 67:16:39:13

20 SDR 135, effective 2/22/1994; 26 SDR 168, effective 7/1/2000; 30 SDR 115, effective 2/4/2004; 35 SDR 88, effective 10/23/2008; 46 SDR 050, effective 10/10/2019; 49 SDR 021, effective 9/12/2022

General Authority: SDCL 28-6-1(1)(2)(4).

Law Implemented: SDCL 28-6-1.

Records, ch 67:16:34.