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 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 payments from this charge;
7. (7) The procedure code specified in § 67:54:07:15;
8. (8) The units of service furnished if more than one; and

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

   A separate claim form must be used for each recipient.

   Note: The HCFA 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: 23 SDR 8, effective July 21, 1996.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.