A claim for services provided under this chapter must be submitted on a form available from the department or the claim may be electronically transmitted through a system approved by the department. The claim must contain 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) Date of service;
4. (4) As specified in the provider's contract with the department, the provider's rate of payment for the service provided;
5. (5) The units of service furnished, if more than one; and

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

   A separate claim form must be used for each recipient.

Source: 17 SDR 4, effective July 16, 1990; 17 SDR 22, effective August 14, 1990; 18 SDR 78, effective November 4, 1991; 19 SDR 26, effective August 23, 1992; 19 SDR 165, effective May 3, 1993; 20 SDR 149, effective March 21, 1994; 21 SDR 183, effective April 30, 1995; 28 SDR 96, effective December 30, 2001.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.