67:16:35:06. Medical assistance cross-over claim requirements. A cross-over claim may be submitted to the department if the provider's claim to Medicare did not trigger an automatic payment of the deductible or coinsurance. Proof of payment by Medicare must be attached. A cross-over claim must contain the following information:
(1) The provider's name and National Provider Identification (NPI) number and taxonomy code;
(2) The recipient's full name and medical assistance identification number from the recipient's medical assistance 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 billed to Medicare;
(7) Units of service furnished, if more than one;
(8) The applicable procedure code from the Health Care Common Procedure Coding System (HCPCS), as adopted in § 67:16:01:27, or the Current Procedural Terminology (CPT), as adopted in § 67:16:01:25;
(9) The amount paid by Medicare plus the Medicare discount or write off amount;
(10) Proof of the deductible or co-insurance, which must be attached;
(11) The amount paid by third-party payers other than Medicare, if any;
(12) The amount originally billed to Medicare; and
(13) The type of Medicare coverage.
Source: 17 SDR 4, effective July 16, 1990; 17 SDR 184, effective June 6, 1991; 40 SDR 122, effective January 7, 2014; 43 SDR 80, effective December 5, 2016.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
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