The department may pend a claim for any of the following general classes of reasons:

1. (1) The claim was submitted with erroneous, incomplete, or missing information;
2. (2) The information on the claim does not match the state master recipient or provider eligibility files;
3. (3) The claim requires action by the department for medical review, manual pricing, individual requests, late submission exceptions, or utilization review;
4. (4) The department erroneously entered the claim into the data processing system;
5. (5) A third-party source exists;
6. (6) The claim is a possible duplicate of another paid claim;
7. (7) The claim is suspected of being false;
8. (8) The claim is incorrect;
9. (9) The claim is submitted by a provider who is currently being investigated by the Medicaid fraud unit; or

10. (10) The claim is submitted by a provider who is currently being reviewed or investigated by the department.

    Claims pended under subdivision (9) or (10) of this section remain pended until the investigation or review is completed. Time limits for processing claims do not apply to claims pended under subdivision (9) or (10) of this section.

    Cross-References:

    Remittance advice, § 67:16:35:14;

    Timely processing of claims -- Time limitation does not apply to claims from providers under investigation for fraud or abuse, 45 C.F.R. § 447.45(d)(4)(iii);

    Payments and obligations to be authorized by law -- Liability to state for unauthorized payments, SDCL 4-8-2.

Source: 17 SDR 184, effective June 6, 1991; 19 SDR 165, effective May 3, 1993.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.