A claim for air or ground ambulance 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 point of origin and the destination of the recipient being transported;
7. (7) The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge;
8. (8) The applicable procedure codes for the services provided;
9. (9) The applicable diagnosis codes or the reason the recipient required the type of transportation provided;
10. (10) The units of service furnished, if more than one;
11. (11) The provider's name and National Provider Identification number; and

12. (12) The reason for any additional attendant provided.

    A separate claim must be submitted for each recipient.

    Claims, chapter 67:16:35.

Source: 17 SDR 4, effective July 16, 1990; 17 SDR 201, 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; 20 SDR 149, effective March 21, 1994; 21 SDR 183, effective April 30, 1995; 35 SDR 253, effective May 12, 2009; 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, 2009-05-12.