The HCFA Form 1450 shall be used as follows:

1. (1) Institutional care practitioners shall use the HCFA Form UB-92 HCFA-1450, adopted by HCFA and in effect as of June 30, 1995, when filing claims for health care services with issuers. When requested by the patient, institutional care providers that bill patients directly shall provide a completed HCFA Form 1450 in addition to any other explanation or information used to bill the patient;

2. (2) Issuers may require institutional care practitioners to use only the following coding system for the initial filing of claims for health care services:

   1. (a) ICD-9-CM codes, in effect as of June 30, 1995;
   2. (b) Revenue codes, in effect as of June 30, 1995;
   3. (c) HCPCS Level 1, Level 2, and Level 3 codes, in effect as of June 30, 1995; and
   4. (d) The information outlined in subdivision 20:06:27:03(3), if the charges include direct service furnished by a health care practitioner and the direct service is not covered by the instructions for the HCFA Form 1450;

3. (3) Hospitals may use the HCFA Form 1500 to supplement a HCFA Form 1450 if necessary in billing patients or their representatives or filing claims with issuers for outpatient services.

   References: HCFA Form 1450: UB-92 HCFA-1450, in effect as of June 30, 1995, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: Carton of 1,000, $67.95.

   The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Fourth Edition, Volumes I and II, 1995; Context Software Systems, Inc., McGraw-Hill, Inc. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: $39.95 each, plus shipping and handling.

   Revenue Codes: UB-92, National Uniform Billing Data Element Specifications as Developed by the National Uniform Billing Committee as of January 8, 1993, effective October 1, 1993, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the South Dakota Division of Insurance, 124 South Euclid Avenue, 2^nd floor, Pierre, SD 57501-5070. Cost: $.75 a page.

   HCPCS Level 1 Codes: Physicians' Current Procedural Terminology (CPT95), Fourth edition, revised 1994, American Medical Association. Copies may be obtained from American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: $41.95 each, plus shipping and handling.

   Level 2 HCPCS Code: HCFA Common Procedure Coding System (HCPCS), (Alpha-Numeric Portion), in effect as of January, 1995, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from Superintendent of Documents, Publication Service Section 5505, Washington, DC 20402. Cost: $16 each.

   Level 3 HCPCS Code: HCPCS 1995, November 7, 1994, pp. 161-163. Denver Region VIII, 00820 North Dakota B/S, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the South Dakota Division of Insurance, 124 South Euclid Avenue, 2^nd Floor, Pierre, SD 57501-5070. Cost: $.75 a page.

Source: 22 SDR 97, effective December 18, 1995; 42 SDR 52, effective October 13, 2015.

General Authority: SDCL 58-12-14.

Law Implemented: SDCL 58-12-12.

Prior versions effective: 1995-12-18.