A claim for private duty nursing and extended home health aide services provided in 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 payments from this charge;
7. (7) The applicable procedure codes for the covered services provided;
8. (8) The applicable diagnosis codes;
9. (9) The units of service furnished, if more than one;
10. (10) The provider's name and National Provider Identification number; and

11. (11) The prior authorization number issued by the department.

    A separate claim form must be used for each recipient.

    Claims, chapter 67:16:35.

Source: 18 SDR 209, effective June 23, 1992; 19 SDR 26, effective August 23, 1992; 19 SDR 128, effective March 11, 1993; 20 SDR 149, effective March 21, 1994; 21 SDR 183, effective April 30, 1995; 35 SDR 88, effective October 23, 2008; 42 SDR 51, effective October 13, 2015 ; 52 SDR 126, effective July 1, 2026 .

General Authority: SDCL 28-6-1 .

Law Implemented: SDCL 28-6-1 .

Prior versions effective: 2015-10-13, 2008-10-23.