S.D. Admin. R. 67:16:25:10

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

Section 67:16:25:10 - Claim requirements - Ambulance

A claim for air or ground ambulance 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 point of origin and the destination of the recipient being transported;

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

(8) The applicable procedure codes for the services provided;

(9) The applicable diagnosis codes adopted in § 67:16:01:26, or the reason the recipient required the type of transportation provided;

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

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

(12) The reason for any additional attendant provided. A separate claim must be submitted for each recipient.

S.D. Admin. R. 67:16:25:10

17 SDR 4, effective 7/16/1990; 17 SDR 201, 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; 20 SDR 149, effective 3/21/1994; 21 SDR 183, effective 4/30/1995; 35 SDR 253, effective 5/12/2009; 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.

Claims, ch 67:16:35.