S.D. Admin. R. 67:16:43:09

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

Section 67:16:43:09 - Claim requirements

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

(1) The child's full name;

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

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

(4) Date of service;

(5) The provider's current daily rate. The provider may not subtract other third-party or cost-sharing from this charge;

(6) Units of service furnished, if more than one;

(7) The applicable diagnosis codes adopted in § 67:16:01:26;

(8) The provider's name and National Provider Identification (NPI)number;

(9) Type of admission;

(10) The prior authorization number assigned by the care manager;

(11) The revenue code; and

(12) The type of bill.

S.D. Admin. R. 67:16:43:09

23 SDR 2, effective 7/15/1996; 42 SDR 51, effective 10/13/2015

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

Note: The CMS 1450 (UB-04) 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.