S.D. Admin. R. 67:16:25:12.01

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

Section 67:16:25:12.01 - Claim requirements - Community transportation services

A claim for community transportation 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) Date of service;

(4) The point of origin and the destination of the recipient being transported;

(5) The provider's usual and customary charge;

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

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

(8) The provider's name and National Provider Identification (NPI) number.

A separate claim must be submitted for each recipient.

S.D. Admin. R. 67:16:25:12.01

22 SDR 20, effective 8/24/1995; 35 SDR 253, effective 5/12/2009; 44 SDR 94, effective 12/4/2017

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1(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.