S.D. Admin. R. 67:16:11:17

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

Section 67:16:11:17 - Claim requirements - Orthodontia services

A claim for orthodontia services provided in 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 payments from this charge;

(7) The applicable procedure codes for the covered services provided;

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

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

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

(11) The prior authorization number.

A separate claim form must be submitted for each recipient.

S.D. Admin. R. 67:16:11:17

17 SDR 37, effective 9/11/1990; repealed, 23 SDR 197, effective 5/26/1997; 35 SDR 88, effective 10/23/2008; 42 SDR 51, effective 10/13/2015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.