S.D. Admin. R. 67:16:14:14

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

Section 67:16:14:14 - Claim requirements

A claim for items provided under this chapter must be submitted on a claim 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) The number of days for which the item is supplied;

(4) The name of the drug;

(5) The multiple-source drug override indicator if the brand name is medically necessary;

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

(7) Date of service;

(8) The provider's usual and customary charge or cost, as applicable. The provider may not subtract other third-party or cost-sharing payments from this charge;

(9) Units of service furnished;

(10) The provider's name and National Provider Number (NPI), or the provider's PHS medical assistance identification number if the claim is for a drug covered under a PHS provider agreement;

(11) The prescription number assigned;

(12) The national drug code (NDC) number taken from the package or container used in dispensing the prescription. If the drug dispensed does not have an NDC number or is a compounded product, enter " 0999-2000-00 " on the claim form and further identify the item as a "special attention" item;

(13) The metric quantity of the drug dispensed;

(14) An indication if the prescription was a refilled prescription or was dispensed as a unit dose;

(15) The name or the South Dakota medical assistance provider number of the person prescribing the drug;

(16) The provider's National Council of Prescription Drug Providers (NCPDP) number; and

(17) The prescribing physician or other licensed practitioner's Drug Enforcement Agency (DEA) number.

A claim for a PHS-covered drug must be submitted on a separate claim and may not be combined with a claim for other drugs covered under this chapter even if the provider is the same.

S.D. Admin. R. 67:16:14:14

17 SDR 4, effective 7/16/1990; 17 SDR 200, effective 7/1/1991; 22 SDR 93, effective 1/7/1996; 26 SDR 168, effective 7/1/2000; 31 SDR 214, effective 7/6/2005; 44 SDR 94, effective 12/4/2017

General Authority: SDCL 28-6-1.

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

Claims, ch 67:16:35; Case management -- Primary care provider, ch 67:16:39.