S.D. Admin. R. 67:45:02:12

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

Section 67:45:02:12 - Claim requirements

A claim for services provided under this chapter must be submitted on the CMS 1450 (UB-04) form or in an electronic format that contains the following:

(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 as required under chapter 67:16:26;

(4) Beginning and end dates of service. A provider may only bill for one month at a time;

(5) The number of covered days;

(6) The total charges;

(7) The type of bill;

(8) The provider's name, address, telephone number, and National Provider Identification (NPI) number;

(9) The applicable diagnosis codes adopted in § 67:16:01:26;

(10) The patient status code indicating the patient's status on the final day of service of the billing period; and

(11) The revenue code identifying the specific accommodation, ancillary service, or billing calculation.

A separate claim form must be submitted for each recipient.

S.D. Admin. R. 67:45:02:12

17 SDR 4, effective 7/16/1990; transferred from; 42 SDR 51, effective 10/13/2015

General Authority: SDCL 28-6-1. Law Implemented: SDCL 28-6-1.

Note: The CMS 1450 (UB-04) 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.