A claim for items provided under this chapter must be submitted on a claim 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 number of days for which the item is supplied;
4. (4) The name of the drug;
5. (5) The multiple-source drug override indicator if the brand name is medically necessary;
6. (6) Third-party liability information required under chapter 67:16:26;
7. (7) Date of service;
8. (8) The provider's usual and customary charge or cost, as applicable. The provider may not subtract other third-party or cost-sharing payments from this charge;
9. (9) Units of service furnished;
10. (10) The provider's name and National Provider Number (NPI), or the provider's PHS medical assistance identification number if the claim is for a drug covered under a PHS provider agreement;
11. (11) The prescription number assigned;
12. (12) The national drug code (NDC) number taken from the package or container used in dispensing the prescription. If the drug dispensed does not have an NDC number or is a compounded product, enter "0999-2000-00" on the claim form and further identify the item as a "special attention" item;
13. (13) The metric quantity of the drug dispensed;
14. (14) An indication if the prescription was a refilled prescription or was dispensed as a unit dose;
15. (15) The name or the South Dakota medical assistance provider number of the person prescribing the drug;
16. (16) The provider's National Council of Prescription Drug Providers (NCPDP) number; and

17. (17) The prescribing physician or other licensed practitioner's Drug Enforcement Agency (DEA) number.

    A claim for a PHS-covered drug must be submitted on a separate claim and may not be combined with a claim for other drugs covered under this chapter even if the provider is the same.

    Cross-References: Claims, ch 67:16:35; Case management -- Primary care provider, ch 67:16:39.

Source: 17 SDR 4, effective July 16, 1990; 17 SDR 200, effective July 1, 1991; 22 SDR 93, effective January 7, 1996; 26 SDR 168, effective July 1, 2000; 31 SDR 214, effective July 6, 2005; 44 SDR 94, effective December 4, 2017.

General Authority: SDCL 28-6-1 (2)(4) .

Law Implemented: SDCL 28-6-1 (2)(4) .

Prior versions effective: 2005-07-06.