The department may deny a claim for any of the following reasons:
- (1) The service claimed was not medically necessary;
- (2) The claim is a duplicate of a prior paid claim;
- (3) Third-party liability exists;
- (4) The claim contains data that is logically inconsistent;
- (5) The time limit for the submission of a claim has expired;
- (6) The provider or recipient of service was not eligible when the service was provided;
- (7) The drug is considered less than effective;
- (8) The service is considered experimental;
- (9) The claim contains erroneous, incomplete, or missing information;
- (10) The claim is false or incorrect or violates provisions of this article; or
- (11) The service is incidental to or an integral part of an allowable service.
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.