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

1. (1) The individual’s full name and identification number as they appear on the individual’s medical assistance identification card;
2. (2) Third-party liability information required under chapter 67:16:26;
3. (3) The date of service;
4. (4) The place of service;
5. (5) The type of service;
6. (6) The provider’s usual and customary charge. The provider may not subtract other third-party payments from this charge;
7. (7) The units of service furnished, if more than one;
8. (8) The procedure code T2048;
9. (9) The provider’s name, address, and telephone number;
10. (10) The facility’s medical assistance identification number;
11. (11) The signature of the provider or provider’s representative and the date of the signature; and

12. (12) The prior authorization number issued by the department.

    A separate claim must be submitted for each recipient.

    Note: The CMS 1500 form 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. 20401. Pricing information may be obtained by calling (202) 783-3238.

Source: 32 SDR 33, effective August 31, 2005; 34 SDR 180, effective December 26, 2007.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 26-6-14 , 28-6-1.