Claims submitted under this chapter must meet the following billing requirements:

1. (1) Physician services must follow the billing requirements contained in chapter 67:16:02;
2. (2) Inpatient and outpatient hospital services must follow the billing requirements contained in chapter 67:16:03;
3. (3) Home health services must follow the billing requirements contained in chapter 67:16:05;
4. (4) Screening services must follow the billing requirements contained in chapter 67:16:11;
5. (5) Clinic services must follow the billing requirements contained in chapter 67:16:13;
6. (6) Ambulatory surgical center services must follow the billing requirements contained in chapter 67:16:28;
7. (7) Medical equipment services must follow the billing requirements contained in chapter 67:16:29;
8. (8) Organ transplant services must follow the billing requirements contained in chapter 67:16:31;
9. (9) School district services must follow the billing requirements contained in chapter 67:16:37;
10. (10) Mental health services provided by independent practitioners must follow the billing requirements contained in chapter 67:16:41;
11. (11) Federally qualified health center and rural health clinic services must follow the billing requirements contained in chapter 67:16:44;
12. (12) Diabetes self-management training must follow the billing requirements contained in chapter 67:16:46; and

13. (13) Substance use disorder treatment services must follow the billing requirements contained in chapter 67:16:48.

    A provider may not, on behalf of a recipient, submit a claim for services provided under this chapter unless the provider is the recipient's primary care provider or the covered service was provided as a result of a referral and authorization by the recipient's primary care provider.

    If a recipient's primary care provider submits a claim for covered services, the claim must contain the primary care provider's National Provider Identifier number. If a provider submits a claim for covered services provided as a result of a referral and authorization by the recipient's primary care provider, the claim must contain the provider's National Provider Identifier number and the National Provider Identifier number of the recipient's primary care provider.

    A claim submitted without the required National Provider Identifier number is cause for denial by the department.

Source: 20 SDR 135, effective February 22, 1994; 26 SDR 168, effective July 1, 2000; 30 SDR 115, effective February 4, 2004; 35 SDR 88, effective October 23, 2008; 46 SDR 50, effective October 10, 2019 ; 49 SDR 21, effective September 12, 2022 .

General Authority: SDCL 28-6-1 .

Law Implemented: SDCL 28-6-1 (1)(2)(4) .

Prior versions effective: 2019-10-10, 2008-10-23.