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          67:16:35:15.  Claim submission and resubmission limits. A participating provider may not submit a claim for a provider who has been excluded or terminated from the medical assistance program or who otherwise does not meet provider requirements in this article.

 

          Claims for medically necessary covered services provided prior to a provider's exclusion or termination may be submitted to the department after the exclusion or termination.

 

          A provider may not resubmit a claim to the department if the claim has been pended, has already been paid, has been denied because it is not a covered service or is not a medically necessary covered service, or is in violation of this article. The resubmission of such a claim is considered an abuse of the program and may be cause for terminating the provider agreement.

 

          A previously denied claim may be resubmitted when there is new or additional information which will substantiate the claim or when the previously submitted incorrect data is resubmitted correctly.

 

          Source: 17 SDR 184, effective June 6, 1991; 19 SDR 165, effective May 3, 1993.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

 

          Cross-Reference: Duration of agreement, ยง 67:16:33:04.

 


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