A claim for a substance use disorder treatment service provided under this chapter shall be submitted to the department on a form or in an electronic format and shall contain the following information:

1. (1) The recipient's full name;
2. (2) The recipient's medical assistance identification 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 applicable procedure codes for the covered services provided;
8. (8) The applicable diagnosis codes as adopted in § 67:16:01:26;
9. (9) The units or days of service furnished, if more than one;
10. (10) The provider's name and National Provider Identification (NPI) number; and

11. (11) The prior authorization number issued to the provider by the division for services that require prior authorization.

    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 is acceptable. These forms are available for direct purchase through the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402.

12. (202) 783-3238 - pricing desk.

Source: 43 SDR 80 , effective December 5, 2016 .

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.