Claim requirements.
Effective Jul 1, 202652 SDR 126Source: 17 SDR 4, effective July 16, 1990; 17 SDR 22, effective August 14, 1990; 17 SDR 194, effective July 1, 1991; 18 SDR 78, effective November 4, 1991; 18 SDR 210, effective June 23, 1992; 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; 34 SDR 68, effective September 12, 2007 ; 43 SDR 80, effective December 5, 2016 ; 44 SDR 94, effective December 4, 2017 ; 52 SDR 126, effective July 1, 2026 . | General Authority: SDCL 28-6-1 . | Law Implemented: SDCL 28-6-1 .
A claim for services provided under this chapter must be submitted on a form or in an electronic format that contains the following information:
- (1) The service recipient's full name;
- (2) The recipient's medical assistance identification number from the recipient's medical assistance identification card;
- (3) Third-party liability information required under chapter 67:16:26;
- (4) Date of service;
- (5) Place of service;
- (6) The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge;
- (7) The applicable procedure codes for services covered under this chapter;
- (8) The units of service furnished, if more than one;
- (9) The provider's name and National Provider Identification (NPI) number;
- (10) The ordering provider's NPI number;
- (11) The prior authorization number issued by the department for services requiring prior authorization;
(12) One of the following modifier codes, as applicable, at the end of the procedure code:
- (a) LL - Lease/rental, when rental is to be applied to the purchase price;
- (b) NU - New equipment;
- (c) RP - Replacement and repair;
- (d) RR - Rental, when medical equipment is to be rented; or
- (e) UE - Used medical equipment; and
(13) Special comments if maintenance and repair services are for nursing facility recipients who own their medical equipment.
A separate claim must be submitted for each recipient.
Claims, chapter 67:16:35.
Source: 17 SDR 4, effective July 16, 1990; 17 SDR 22, effective August 14, 1990; 17 SDR 194, effective July 1, 1991; 18 SDR 78, effective November 4, 1991; 18 SDR 210, effective June 23, 1992; 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; 34 SDR 68, effective September 12, 2007 ; 43 SDR 80, effective December 5, 2016 ; 44 SDR 94, effective December 4, 2017 ; 52 SDR 126, effective July 1, 2026 .
General Authority: SDCL 28-6-1 .
Law Implemented: SDCL 28-6-1 .
Prior versions effective: 2017-12-04, 2016-12-05, 2007-09-12.