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

1. (1) The service recipient's full name;
2. (2) The recipient's medical assistance identification number from the recipient's medical assistance identification card;
3. (3) Third-party liability information required under chapter 67:16:26;
4. (4) Date of service;
5. (5) Place of service;
6. (6) The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge;
7. (7) Units of service furnished, if more than one;
8. (8) The applicable procedure codes;
9. (9) The applicable diagnosis codes;
10. (10) The provider's name and National Provider Identification number;
11. (11) If the provider is a group provider, the National Provider Identification number of the physician or applicable enrolled provider who provided the care or service;
12. (12) Type of service; and

13. (13) The modifier code described in § 67:16:02:03.03, as applicable.

    A separate claim must be submitted for each recipient.

    Claims, chapter 67:16:35.

Source: 17 SDR 4, effective July 16, 1990; 17 SDR 22, effective August 14, 1990; 17 SDR 200, effective July 1, 1991; 18 SDR 78, effective November 4, 1991; 19 SDR 26, effective August 23, 1992; 19 SDR 128, effective March 11, 1993; 19 SDR 165, effective May 3, 1993; 20 SDR 149, effective March 21, 1994; 21 SDR 183, effective April 30, 1995; 34 SDR 68, effective September 12, 2007; 40 SDR 122, effective January 7, 2014; 42 SDR 51, effective October 13, 2015; 44 SDR 94, effective December 4, 2017 ; 52 SDR 126, effective July 1, 2026 .

General Authority: SDCL 28-6-1 .

Law Implemented: SDCL 28-6-1 .

Prior versions effective: 2017-12-04, 2015-10-13, 2014-01-07.