Each hospital required to report charge information pursuant to SDCL 34-12E-11 shall provide the following information from the UB-04 form:

1. (1) Record type;
2. (2) Hospital number;
3. (3) Patient control number;
4. (4) Date of birth;
5. (5) Sex;
6. (6) Admission date;
7. (7) Principal diagnosis;
8. (8) Admitting diagnosis;
9. (9) Principal procedure;
10. (10) Discharge date;
11. (11) Patient status; and

12. (12) Total charges.

    For the purposes of this section, "UB-04 form" is a standardized form from the Centers for Medicare and Medicaid Services used to electronically submit claims for health care received in an institutional setting.

Source: 32 SDR 69, effective November 7, 2005; 34 SDR 88, effective September 10, 2007; 35 SDR 183, effective February 2, 2009 ; 52 SDR 41, effective October 27, 2025 .

General Authority: SDCL 34-12E-11 .

Law Implemented: SDCL 34-12E-11 .

Prior versions effective: 2009-02-02.