S.D. Admin. R. 67:16:29:11

Current through Register Vol. 51, page 57, November 12, 2024

Section 67:16:29:11 - Claim requirements

A claim for 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 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 CMS Common Procedure Coding System (HCPCs) or the Physicians' Current Procedural Terminology (CPT) for services covered under this chapter;

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

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

(10) The ordering providers NPI number;

(11) The prior authorization number issued by the department for services requiring prior authorization;

(12) One of the following modifier codes, as applicable, at the end of the procedure code:

(a) LL - Lease/rental, when rental is to be applied to the purchase price;

(b) NU - New equipment;

(c) RP - Replacement and repair;

(d) RR - Rental, when medical equipment is to be rented; or

(e) UE - Used medical equipment.

(13) Special comments if maintenance and repair services are for nursing facility recipients who own their medical equipment.

A separate claim must be submitted for each recipient.

S.D. Admin. R. 67:16:29:11

17 SDR 4, effective 7/16/1990; 17 SDR 22, effective 8/14/1990; 17 SDR 194, effective 7/1/1991; 18 SDR 78, effective 11/4/1991; 18 SDR 210, effective 6/23/1992; 19 SDR 26, effective 8/23/1992; 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; 43 SDR 80, effective 12/5/2016; 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 for this rule and its content and appearance is acceptable. 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.