A claim for services provided under this chapter must be submitted on a form which contains the following information:

1. (1) The recipient's full name;
2. (2) The recipient's medical assistance identification number from the recipient's medical identification card;
3. (3) The third-party liability information required under chapter 67:16:26;
4. (4) The date of service;
5. (5) The 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 units of service furnished, if more than one, for each procedure;
8. (8) The applicable procedure codes;
9. (9) The type of service; and

10. (10) The provider's name and medical assistance identification number.

    A separate claim form must be used for each client.

    Note: The HFCA 1500 form substantially 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. 20402. (202) 783-3238 - pricing desk.

Source: 21 SDR 230, effective July 13, 1995.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.