67 : 16 : 49 : 06 . Claim requirements. A claim for travel services provided under this chapter shall be submitted on a form available from the department. The form 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) The name and address of the individual who is to receive payment for the travel services provided;
4. (4) If applicable, the name of the charitable organization that advanced funds and the amount advanced;
5. (5) The city of origin and the destination city;
6. (6) The departure date and the return date;
7. (7) The mode of transportation;
8. (8) The name of the medical facility to which the recipient is traveling and the doctor's name, national provider identification number, and specialty;
9. (9) The purpose of the visit; and

10. (10) The medical appointment date and time or if applicable, dates of hospitalization.

    If claiming lodging expenses, the receipt from the hotel must be attached to the claim.

    The claim must be signed and dated by the medical provider and the recipient, parent, or guardian.

    A charitable organization may submit an invoice that contains the above-referenced information instead of submitting the department's claim form.

Source: 44 SDR 94, effective December 4, 2017.

General Authority: SDCL 28-6-1(1)(2) ( 4).

Law Implemented: SDCL 28-6-1(1)(2)(4).