S.D. Admin. R. 67:16:02:17

Current through Register Vol. 51, page 67, December 16, 2024

Section 67:16:02:17 - 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) Units of service furnished if more than one;

(8) The applicable procedure codes from either the Health Care Common Procedure Coding System (HCPCS) or the Current Procedural Terminology (CPT);

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

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

(11) If the provider is a group provider, the National Provider Identification number of the physician or applicable, enrolled provider who provided the care or service;

(12) Type of service; and

(13) The modifier code listed in § 67:16:02:03.03, as applicable.

A separate claim must be submitted for each recipient.

S.D. Admin. R. 67:16:02:17

17 SDR 4, effective 7/16/1990; 17 SDR 22, effective 8/14/1990; 17 SDR 200, effective 7/1/1991; 18 SDR 78, effective 11/4/1991; 19 SDR 26, effective 8/23/1992; 19 SDR 128, effective 3/11/1993; 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; 40 SDR 122, effective 1/7/2014; 42 SDR 51, effective 10/13/2015; 44 SDR 94, effective 12/4/2017

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1(2)(4).

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.