A claim submitted under this chapter must be submitted at the provider's usual and customary charge and must contain the applicable procedure codes contained in § 67:16:46:05. The claim for services must be submitted on a form that contains the following information:

1. (1) The recipient's full name;
2. (2) The recipient's medical assistance number from the recipient's medical assistance 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 payments from this charge;
7. (7) The procedure codes for services covered under § 67:16:46:05;
8. (8) The units of service furnished, if more than one; and

9. (9) The provider's name and National Provider Identification number.

   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: 28 SDR 84, effective December 20, 2001; 40 SDR 122, effective January 7, 2014.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.