S.D. Admin. R. 67:16:13:09
Current through Register Vol. 51, page 57, November 12, 2024
Section 67:16:13:09 - Claim requirements A claim for services provided under this chapter must be submitted on a form which 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;(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 (CPT) for services covered under this chapter;(8) The applicable diagnosis codes adopted in § 67:16:01:26;(9) The units of service furnished, if more than one;(10) The billing provider's name and National Provider Identification (NPI) number; and(11) The National Provider Identification (NPI) number of the servicing provider who provided or supervised the care or service. A separate claim form must be used for each recipient.
S.D. Admin. R. 67:16:13:09
17 SDR 4, effective 7/16/1990; 17 SDR 22, effective 8/14/1990; 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; 42 SDR 51, effective 10/13/2015; 43 SDR 80, effective 12/5/2016General 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.