<html> <head> <title>Rule 67:16:35:15 Claim submission and resubmission limits.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:15"> <META NAME="Description" Content="Administrative Rules 67:16:35:15 Claim submission and resubmission limits."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:15.&nbsp;&nbsp;Claim submission and resubmission limits.</b> 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.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 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.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 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.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 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.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 184, effective June 6, 1991; 19 SDR 165, effective May 3, 1993.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Cross-Reference:</b> Duration of agreement, §&nbsp;67:16:33:04.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html>