67:16:11:19.02. Claim requirements -- Private duty nursing -- Extended home health
aide services. A claim for private duty nursing and extended home health
aide services provided in this chapter must be submitted on a form or in an
electronic format that contains the following information:
(1) The recipient's
(2) The recipient's
medical assistance identification number from the recipient's medical
assistance identification card;
liability information required under chapter 67:16:26;
(4) Date of
(5) Place of
(6) The provider's
usual and customary charge. The provider may not subtract other third-party
payments from this charge;
(7) The applicable
procedure codes for the covered services provided;
(8) The applicable
diagnosis codes adopted in § 67:16:01:26;
(9) The units of
service furnished, if more than one;
(10) The provider's
name and National Provider Identification (NPI) number; and
(11) The prior
authorization number issued by the department.
A separate claim form must be
used for each recipient.
Source: 18 SDR 209,
effective June 23, 1992; 19 SDR 26, effective August 23, 1992; 19 SDR 128,
effective March 11, 1993; 20 SDR 149, effective March 21, 1994; 21 SDR 183,
effective April 30, 1995; 35 SDR 88, effective October 23, 2008; 42 SDR 51,
effective October 13, 2015.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Claims, ch 67:16:35.
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.