A claim for services provided under this chapter must be submitted on a form that contains the following information:
- (1) The child's full name;
- (2) The child's medical assistance identification number from the child's medical identification card;
- (3) Third-party liability information required under chapter 67:16:26;
- (4) Date of service;
- (5) The provider's current daily rate. The provider may not subtract other third-party or cost-sharing from this charge;
- (6) Units of service furnished, if more than one;
- (7) The applicable diagnosis codes;
- (8) The provider's name and National Provider Identification number;
- (9) Type of admission;
- (10) The prior authorization number assigned by the care manager;
- (11) The revenue code; and
- (12) The type of bill.
Source: 23 SDR 2, effective July 15, 1996; 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, 1996-07-15.