S.D. Admin. R. 67:16:37:15

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

Section 67:16:37:15 - Claim requirements

A claim for services provided under this chapter must be submitted on a form which 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 third-party liability information required under chapter 67:16:26;

(4) The date of service;

(5) The 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 procedure codes designated for services covered under this chapter, listed on the department's billing guidance website;

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

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

(10) The National Provider Identification (NPI) number of the servicing provider who provided or supervised the care or service.

A separate claim form must be used for each recipient.

S.D. Admin. R. 67:16:37:15

18 SDR 78, effective 11/4/1991; 18 SDR 224, effective 7/13/1992; 40 SDR 122, effective 1/7/2014; 40 SDR 229, effective 6/30/2014; 42 SDR 51, effective 10/13/2015; 43 SDR 80, effective 12/5/2016

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.