CHAPTER 20:06:27
STANDARDIZED HEALTH CARE FORMS
Section
20:06:27:01 Definitions.
20:06:27:02 Scope.
20:06:27:03 Requirements for use of HCFA Form 1500.
20:06:27:04 Requirements for use of HCFA Form 1450.
20:06:27:05 Requirements for use of J512 Form.
20:06:27:06 General provisions for the filing and processing of claims.
20:06:27:07 Mandatory electronic format.
20:06:27:01. Definitions. Terms used in this section mean:
(1) "ASC Z12N standard format," the standards for electronic data interchange within the health care industry developed by the Accredited Standards Committee Z12N Insurance Subcommittee of the American National Standards Institute;
(2) "CDT-2 codes," the current dental terminology prescribed by the American Dental Association;
(3) "CPT-4 codes," codes for medical services and procedures performed by medical providers as listed in Physicians Current Procedural Terminology, (CPT '95) Fourth Edition, published by the American Medical Association;
(4) "HCFA," the Health Care Financing Administration of the U.S. Department of Health and Human Services;
(5) "HCFA Form 1450," the health insurance claim form maintained by HCFA for use by institutional care practitioners;
(6) "HCFA Form 1500," the health insurance claim form maintained by HCFA for use by health care practitioners;
(7) "HCPCS," HCFA's common procedure coding system which describes products, supplies, procedures, and health professional services;
(8) "HCPCS Level 1 Codes," the AMA's CPT-4 codes and modifiers for professional services and procedures;
(9) "HCPCS Level 2 Codes," alphanumeric codes and modifiers for health care products and supplies, as well as some codes for professional services not included in the AMA's CPT-4;
(10) "HCPCS Level 3 Codes," local alphanumeric codes and modifiers for items and services not included in the HCPCS Level 1 or HCPCS Level 2;
(11) "Health care practitioner," a provider of health care as follows:
(a) A chiropractor licensed under SDCL chapter 36-5;
(b) A corporation or partnership of health care practitioners listed in this subdivision;
(c) A dentist licensed under SDCL chapter 36-6A;
(d) A nurse licensed under SDCL chapter 36-9 or 36-9A;
(e) An optometrist licensed under SDCL chapter 36-7;
(f) A physician licensed under SDCL chapter 36-4;
(g) A podiatrist licensed under SDCL chapter 36-8;
(h) A psychologist licensed under SDCL chapter 36-27A;
(i) A speech, physical, respiratory, or occupational therapist licensed under SDCL chapter 36-10 or 36-31;
(j) A medical assistant licensed under SDCL chapter 36-9B;
(k) A physician assistant licensed under SDCL chapter 36-4A; or
(l) An emergency medical technician licensed under SDCL chapter 36-4B;
(12) "ICD-9-CM codes," the diagnosis and procedure codes in the International Classification of Diseases, Ninth Revision, Clinical Modification published by the U.S. Department of Health and Human Services;
(13) "Institutional care practitioner," a facility licensed under SDCL chapter 34-12 or listed in § 44:04:01:02;
(14) "Issuer," an insurance company, fraternal benefit society, health care service plan, health maintenance organization, third party administrator, and any other entity reimbursing the costs of health care expenses;
(15) "J512 form," the uniform dental claim form approved by the American Dental Association for use by dentists;
(16) "Revenue codes," the codes established for use by institutional care practitioners by the National Uniform Billing Committee.
Source: 22 SDR 97, effective December 18, 1995.
General Authority: SDCL 58-12-14.
Law Implemented: SDCL 58-12-12.
20:06:27:02. Scope. Except as otherwise specifically provided, the requirements of this chapter apply to issuers, health care providers, and institutional care practitioners. Nothing in this chapter prevents an issuer from requesting additional information that is not contained on the required forms to determine eligibility of the claim for payment if required under the terms of the policy, certificate, program, or plan the claimant is covered under. Nothing in this chapter prohibits an issuer, health care practitioner, or institutional care practitioner from using alternative forms or procedures for filing claims as specified in a written contract between the health care practitioner or institutional care practitioner and issuer. Nothing in this chapter applies to disability insurance.
Source: 22 SDR 97, effective December 18, 1995.
General Authority: SDCL 58-12-14.
Law Implemented: SDCL 58-12-12.
20:06:27:03. Requirements for use of HCFA Form 1500. The HCFA Form 1500 shall be used as follows:
(1) Health care practitioners, other than dentists, shall use the HCFA Form 1500, adopted by HCFA, approved by AMA Council on Medical Service in August, 1988, and in effect in May of 1995, when filing claims for professional services with issuers. Health care practitioners that bill patients directly shall provide a completed HCFA Form 1500 in addition to any other explanatory information used to bill the patient if requested by the patient. Issuers may only require health care practitioners to use the following coding systems for the initial filing of claims for health care services:
(a) HCPCS Level 1, Level 2, and Level 3 codes in effect as of June 30, 1995; and
(b) ICD-9-CM codes in effect as of June 30, 1995;
(2) Issuers may only require health care practitioners to use other explanations with a code or to furnish additional information with the initial submission of a HCFA Form 1500 under the following circumstances:
(a) If the procedure code used describes a treatment or service that is not otherwise classified;
(b) If the procedure code is followed by the CPT-4 modifier 22, 52, or 99, pursuant to the CPT-4 manual in effect as of June 30, 1995. Health care practitioners may use item 19 of the HCFA Form 1500 to explain multiple modifiers, unless box 19 is used for other purposes in accordance with the instructions for this form; or
(c) If information contained in the code is insufficient to process the claim or, in the case of a public program, is necessary to administer the program;
(3) Health care practitioners may use box 19 of the HCFA Form 1500 to indicate the form is an amended version of a form previously submitted to the issuer by inserting the word "amended" in the space provided;
(4) Except as otherwise required through participation in Medicaid, health care practitioners billing for services based on the amount of time involved shall define on line 19 the time interval in item 24 G of the HCFA Form 1500, if the time interval is not already defined in the HCPCS code. If not defined by either HCPCS or in line 19, the issuer shall assume units to be days of treatment;
(5) Except as otherwise required through participation in Medicaid, as authorized by Title XIX of the Social Security Act, 42 U.S.C. § 1396d, health care practitioners shall provide the unique physician identification number, as assigned by HCFA, in box 17a and the federal tax identification number or social security number to complete item 25 of the HCFA Form 1500.
Source: 22 SDR 97, effective December 18, 1995; 42 SDR 52, effective October 13, 2015.
General Authority: SDCL 58-12-14.
Law Implemented: SDCL 58-12-12.
References: HCFA Form 1500 (12/90), in effect as of May, 1995, Health Care Financing Administration. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: Carton of 1,000, $67.95.
HCPCS Level 1 Codes: Physicians' Current Procedural Terminology (CPT '95), Fourth edition, revised 1994, American Medical Association. Copies may be obtained from American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: $41.95 each, plus shipping and handling.
HCPCS Level 2 Code: HCFA Common Procedure Coding System (HCPCS), (Alpha-Numeric Portion), January, 1995, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from Superintendent of Documents, Publication Service Section 5505, Washington, DC 20402. Cost: $16 each.
Level 3 HCPCS Code: HCPCS 1995, November 7, 1994, pp. 161-163. Denver Region VIII, 00820 North Dakota B/S, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the South Dakota Division of Insurance, 124 South Euclid Avenue, 2nd Floor, Pierre, SD 57501-5070. Cost: $.75 a page.
The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Fourth Edition, Volumes I and II, 1995: Context Software Systems, Inc., McGraw-Hill, Inc. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: $39.95 each, plus shipping and handling.
20:06:27:04. Requirements for use of HCFA Form 1450. The HCFA Form 1450 shall be used as follows:
(1) Institutional care practitioners shall use the HCFA Form UB-92 HCFA-1450, adopted by HCFA and in effect as of June 30, 1995, when filing claims for health care services with issuers. When requested by the patient, institutional care providers that bill patients directly shall provide a completed HCFA Form 1450 in addition to any other explanation or information used to bill the patient;
(2) Issuers may require institutional care practitioners to use only the following coding system for the initial filing of claims for health care services:
(a) ICD-9-CM codes, in effect as of June 30, 1995;
(b) Revenue codes, in effect as of June 30, 1995;
(c) HCPCS Level 1, Level 2, and Level 3 codes, in effect as of June 30, 1995; and
(d) The information outlined in subdivision 20:06:27:03(3), if the charges include direct service furnished by a health care practitioner and the direct service is not covered by the instructions for the HCFA Form 1450;
(3) Hospitals may use the HCFA Form 1500 to supplement a HCFA Form 1450 if necessary in billing patients or their representatives or filing claims with issuers for outpatient services.
Source: 22 SDR 97, effective December 18, 1995; 42 SDR 52, effective October 13, 2015.
General Authority: SDCL 58-12-14.
Law Implemented: SDCL 58-12-12.
References: HCFA Form 1450: UB-92 HCFA-1450, in effect as of June 30, 1995, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: Carton of 1,000, $67.95.
The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Fourth Edition, Volumes I and II, 1995; Context Software Systems, Inc., McGraw-Hill, Inc. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: $39.95 each, plus shipping and handling.
Revenue Codes: UB-92, National Uniform Billing Data Element Specifications as Developed by the National Uniform Billing Committee as of January 8, 1993, effective October 1, 1993, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the South Dakota Division of Insurance, 124 South Euclid Avenue, 2nd floor, Pierre, SD 57501-5070. Cost: $.75 a page.
HCPCS Level 1 Codes: Physicians' Current Procedural Terminology (CPT 95), Fourth edition, revised 1994, American Medical Association. Copies may be obtained from American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: $41.95 each, plus shipping and handling.
Level 2 HCPCS Code: HCFA Common Procedure Coding System (HCPCS), (Alpha-Numeric Portion), in effect as of January, 1995, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from Superintendent of Documents, Publication Service Section 5505, Washington, DC 20402. Cost: $16 each.
Level 3 HCPCS Code: HCPCS 1995, November 7, 1994, pp. 161-163. Denver Region VIII, 00820 North Dakota B/S, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the South Dakota Division of Insurance, 124 South Euclid Avenue, 2nd Floor, Pierre, SD 57501-5070. Cost: $.75 a page.
20:06:27:05. Requirements for use of J512 Form. The J512 Form shall be used as follows:
(1) Dentists shall use the Dental Claim Form, J512, adopted by the American Dental Association as of 1994, according to instructions contained in the American Dental Association's Current Dental Terminology CDT-2, 1995-2000, for filing claims with issuers for professional dental services. When requested by the patient, dentists that bill patients directly shall provide the patient with a completed J512 Form in addition to any other form used to bill the patient;
(2) Issuers may not require a dentist to use any code other than the CDT-2 codes for the initial filing of claims for dental care services, unless the use of supplemental codes is defined and permitted in a written contract between the issuer and dentist;
(3) Dentists performing procedures within their scope of practice which do not have assigned CDT-2 codes may use the HCFA 1500 Form with the applicable CPT-4 codes. Issuers must accept the J512 Form or, as applicable, the HCFA 1500 Form.
Source: 22 SDR 97, effective December 18, 1995.
General Authority: SDCL 58-12-14.
Law Implemented: SDCL 58-12-12.
References: Form J512, adopted in 1994, American Dental Association. Copies may be obtained from the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Cost: $25.20, plus $3.95 for shipping and handling.
Current Dental Terminology CDT-2, Second Edition, 1995-2000, American Dental Association. Copies may be obtained from the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Cost: $29.95.
Physicians' Current Procedural Terminology CPT'95, Fourth Edition, 1994, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: $41.95, plus shipping and handling.
20:06:27:06. General provisions for the filing and processing of claims. Health care practitioners, institutional care practitioners, and issuers shall file and process claims in the following manner:
(1) Health care practitioners and institutional care practitioners shall file claims in a manner consistent with the requirements of this chapter. Claims filed in paper form must be printed on 8.5 x 11-inch paper;
(2) Issuers shall accept forms submitted in compliance with this chapter for the processing of claims;
(3) Health care practitioners, institutional care practitioners, and issuers shall:
(a) Use and accept HCFA Form 1500, HCFA Form 1450, and J512 Form and the instructions for these forms in the billing of patients or their representatives and filing claims with issuers; and
(b) Modify their billing and claim reimbursement practices to encompass the coding changes for all billing and claim filing by the effective date of the changes set forth by the developers of the forms, codes, and procedures required under this chapter.
Source: 22 SDR 97, effective December 18, 1995.
General Authority: SDCL 58-12-14.
Law Implemented: SDCL 58-12-12.
References: HCFA Form 1500 (12/90), in effect as of May, 1995, Health Care Financing Administration. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: Carton of 1,000, $67.95.
HCFA Form 1450: UB-92 HCFA-1450, in effect as of June 30, 1995, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: Carton of 1,000, $67.95.
Form J512, adopted in 1994, American Dental Association. Copies may be obtained from the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Cost: $25.20, plus $3.95 for shipping and handling.
20:06:27:07. Mandatory electronic format. Issuers that receive claims or send payments by electronic means shall, by the date on which the Health Care Financing Administration requires it of Medicare intermediaries and carriers, accept the ASC X12N standard format for the health care claims submission transaction set (837) and send the ASC X12N health care claim payment transaction set (835), both of which have been adopted by the Data Interchange Standards Association, Inc. (DISA) as of December, 1994.
Source: 22 SDR 97, effective December 18, 1995.
General Authority: SDCL 58-12-14.
Law Implemented: SDCL 58-12-12.
Reference: ASC X12N Draft Version 3, Release 5 Standards, published December, 1994, by the Data Interchange Standards Association, Inc. (DISA) and distributed by Washington Publishing Company (WPC). Copies of the entire standards manual may be obtained from EDI Support Services, P.O. Box 203, Chadron, OH 44024-0203. Cost: $425 each.
