Each month the Department of Social Services shall send a two-part claim form (nursinghomerequestforpayment) to the provider. The first part contains a list of the recipients who were present at the provider's facility during the last billing period. The provider must complete the second part by correcting any errors or changes in the list in the first part and adding information on the new residents.

1. (1) 0 - reserved bed days;
2. (2) 1 - transferred to a hospital;
3. (3) 2 - transferred to another nursing facility;
4. (4) 4 - reserved bed days - individual died;
5. (5) 5 - discharged to home for self-care;
6. (6) 6 - discharged to home under home health agency care;
7. (7) 7 - left against advice;
8. (8) 8 - died;
9. (9) 9 - individual on therapeutic leave; or

10. (10) Blank - individual remains in care.

    If the claim is being submitted to adjust or void a previously submitted claim, the provider must include the reference number of the claim being adjusted or voided.

The provider or the provider's authorized agent must sign and date the form even if there are no changes or additions and return the form to the Department of Social Services. The completed form must contain each recipient's full name, recipient's identification number, date of service, credit amount, level of care, and status. The provider must use one of the following codes to indicate the individual's status:

Source: 20 SDR 170, effective April 18, 1994.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.