S.D. Admin. R. 67:16:47:12

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

Section 67:16:47:12 - 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 individuals full name and identification number as they appear on the individuals medical assistance identification card;

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

(3) The date of service;

(4) The place of service;

(5) The type of service;

(6) The providers usual and customary charge. The provider may not subtract other third-party payments from this charge;

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

(8) The procedure code T2048;

(9) The providers name, address, and telephone number;

(10) The facilitys medical assistance identification number;

(11) The signature of the provider or providers representative and the date of the signature; and

(12) The prior authorization number issued by the department.

A separate claim must be submitted for each recipient.

S.D. Admin. R. 67:16:47:12

32 SDR 33, effective 8/31/2005; 34 SDR 180, effective 12/26/2007.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 26-6-14, 28-6-1.

Note: The CMS 1500 form 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. 20401. Pricing information may be obtained by calling (202) 783-3238.