S.D. Admin. R. 67:16:44:10

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

Section 67:16:44:10 - Claim requirements

A claim for services provided under this chapter must be submitted on a form or in an electronic format that 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 contained in either Health Care Common Procedure Coding System (HCPCS) or Current Procedural Terminology for services covered under this chapter;

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

(9) The provider's name and National Provider Identification (NPI) number.

A separate claim must be submitted for each recipient.

S.D. Admin. R. 67:16:44:10

23 SDR 109, effective 1/5/1997; 33 SDR 44, effective 9/20/2006; 34 SDR 68, effective 9/12/2007; 42 SDR 51, effective 10/13/2015

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.