A claim for services provided under this chapter must be submitted on a form which contains 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) The third-party liability information required under chapter 67:16:26;
4. (4) The date of service;
5. (5) The place of service;
6. (6) The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge;
7. (7) The procedure codes designated for services covered under this chapter, listed on the department's billing guidance website;
8. (8) The units of service furnished, if more than one;
9. (9) The billing provider's name and National Provider Identification (NPI) number; and

10. (10) The National Provider Identification (NPI) number of the servicing provider who provided or supervised the care or service.

    A separate claim form must be used for each recipient.

    Note: The CMS 1500 form substantially meets the requirements of this rule and its content and appearance are acceptable to the department. These forms are available for direct purchase through the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402. (202) 783-3238 - pricing desk.

Source: 18 SDR 78, effective November 4, 1991; 18 SDR 224, effective July 13, 1992; 40 SDR 122, effective January 7, 2014; 40 SDR 229, effective June 30, 2014; 42 SDR 51, effective October 13, 2015 ; 43 SDR 80, effective December 5, 2016 .

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

Prior versions effective: 2015-10-13, 2014-06-30, 2014-01-07.