A claim for services provided under this chapter must be submitted on a form or in an electronic format that contains the following information:
- (1) The participant's full name;
- (2) The participant's medical assistance identification number from the participant's medical identification card;
- (3) Third-party liability information required under chapter 67:16:26;
- (4) The date of service;
- (5) The place of service;
- (6) The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing from this charge;
- (7) The units of service furnished, if more than one, for claims submitted for respite care, service coordination, personal care, companion care, or supported employment;
- (8) The applicable procedure codes contained in § 67:54:09:18;
- (9) The applicable diagnosis codes;
- (10) The provider's name and National Provider Identification number; and
(11) The type of service provided.
A separate claim must be submitted for each participant.
Claims, chapter 67:16:35.
Source: 34 SDR 271, effective May 7, 2008; SL 2013, ch 128, § 38, effective July 1, 2013; 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, 2013-07-01.