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 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 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.
Cross-Reference: 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.