S.D. Admin. R. 67:16:35:13

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

Section 67:16:35:13 - Denied claims

The department may deny a claim for any of the following reasons:

(1) The service claimed was not medically necessary;

(2) The claim is a duplicate of a prior paid claim;

(3) Third-party liability exists;

(4) The claim contains data that is logically inconsistent;

(5) The time limit for the submission of a claim has expired;

(6) The provider or recipient of service was not eligible when the service was provided;

(7) The drug is considered less than effective;

(8) The service is considered experimental;

(9) The claim contains erroneous, incomplete, or missing information;

(10) The claim is false or incorrect or violates provisions of this article; or

(11) The service is incidental to or an integral part of an allowable service.

S.D. Admin. R. 67:16:35:13

17 SDR 184, effective 6/6/1991; 19 SDR 165, effective 5/3/1993.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

Payments and obligations to be authorized by law -- Liability to state for unauthorized payments, SDCL 4-8-2.