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          67:16:28:10.  Claim requirements. A claim for services provided under this chapter must be submitted on a form which contains the following information:


          (1)  The recipient's full name;

          (2)  The recipient's medical assistance identification number from the recipient's medical assistance identification card;

          (3)  Third-party liability information required under chapter 67:16:26;

          (4)  Date of service;

          (5)  Place of service;

          (6)  The provider's usual and customary charge.  The provider may not subtract other third-party or cost-sharing payments from this charge;

          (7)  The applicable procedure codes as contained in either CMS Common Procedure Coding System (HCPCS) or the Physicians' Current Procedural Terminology (CPT) for services covered under § 67:16:28:04;

          (8)  The units of service furnished, if more than one; and

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


          A separate claim form must be used for each recipient.


          Source: 17 SDR 4, effective July 16, 1990; 17 SDR 22, effective August 14, 1990; 18 SDR 78, effective November 4, 1991; 19 SDR 26, effective August 23, 1992; 19 SDR 165, effective May 3, 1993; 20 SDR 149, effective March 21, 1994; 21 SDR 183, effective April 30, 1995; 34 SDR 68, effective September 12, 2007; 43 SDR 80, effective December 5, 2016.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.



          Claims, ch 67:16:35.

          Use of CPT, § 67:16:01:25.

          Use of HCPCS, § 67:16:01:27.


          Note: The CMS 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.


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