S.D. Admin. R. 67:54:09:19

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

Section 67:54:09:19 - Claim requirements

A claim for services provided under this chapter shall be submitted on a form or in an electronic format that contains the following information:

(1) The participant's full name;

(2) The participant's medical assistance identification number from the participant's medical identification card;

(3) 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 from this charge;

(7) The units of service furnished, if more than one, for claims submitted for respite care, service coordination, personal care, companion care, or supported employment;

(8) The applicable procedure codes contained in § 67:54:09:18 for the services provided;

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

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

(11) The type of service provided.

A separate claim shall be submitted for each participant.

S.D. Admin. R. 67:54:09:19

34 SDR 271, effective 5/7/2008; SL 2013, ch 128; 42 SDR 51, effective 10/13/2015

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.

Claims, ch 67:16:35.