A claim for services provided under this chapter must be submitted on a form that contains the following information:

1. (1) The service recipient's full name;
2. (2) The recipient's medical assistance identification number from the recipient's medical identification card;
3. (3) Third-party liability information required under chapter 67:16:26;
4. (4) Date of service;
5. (5) Place of service;
6. (6) The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing from this charge;
7. (7) Units of service furnished, if more than one;
8. (8) The applicable procedure codes contained in § 67:16:41:09;
9. (9) The applicable diagnosis codes;
10. (10) The provider's name and National Provider Identification number; and

11. (11) Type of service provided.

    Claims, chapter 67:16:35.

Source: 22 SDR 6, effective July 26, 1995; 40 SDR 122, effective January 7, 2014; 42 SDR 51, effective October 13, 2015 ; 52 SDR 126, effective July 1, 2026 .

General Authority: SDCL 28-6-1 .

Law Implemented: SDCL 28-6-1 .

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