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          67:16:42:13.  Claim requirements. A claim for nutritional items and supplies provided under this chapter must be submitted on a form or in an electronic format that 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 for the items and services provided;

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

          (9)  The provider's name and National Provider Identification (NPI) number; and

          (10)  If applicable, the prior authorization number issued to the provider by the department.


          A separate claim form must be submitted for each recipient.


          Source: 17 SDR 37, effective September 11, 1990; transferred from ยง 67:16:11:16, 22 SDR 32, effective September 11, 1995; 35 SDR 49, effective September 10, 2008; 43 SDR 80, effective December 5, 2016.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.


          Note: The CMS 1500 form substantially meets the requirements of this rule and its content and appearance is acceptable. 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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