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

1. (1) The service 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 as required under chapter 67:16:26;
4. (4) Beginning and end dates of service. A provider may only bill for one month at a time;
5. (5) The number of covered days;
6. (6) The total charges;
7. (7) The type of bill;
8. (8) The provider's name, address, telephone number, and National Provider Identification number;
9. (9) The applicable diagnosis codes;
10. (10) The patient status code indicating the patient's status on the final day of service of the billing period; and

11. (11) The revenue code identifying the specific accommodation, ancillary service, or billing calculation.

    A separate claim form must be submitted for each recipient.

Source: 17 SDR 4, effective July 16, 1990; transferred from § 67:16:04:31 , 18 SDR 67, effective October 13, 1991; 40 SDR 122, effective January 7, 2014; 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, 2014-01-07.