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

1. (1) The recipient's full name;
2. (2) The recipient's medical assistance identification number from the recipient's medical assistance identification card;
3. (3) The third-party liability information required under chapter 67:16:26;
4. (4) The date of service;
5. (5) The applicable procedure codes for the covered services provided; and

6. (6) The provider's name and national provider identification number.

   A separate claim form must be used for each recipient.

   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.

Source: 19 SDR 82, effective December 7, 1992; 35 SDR 88, effective October 23, 2008.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.