CHAPTER 67:16:35
CLAIMS
Section
67:16:35:01 Definitions.
67:16:35:02 Verification of eligibility before claim submitted.
67:16:35:03 Claims limited to items and services covered under article.
67:16:35:04 Time limits for submission of claims.
67:16:35:05 Electronic media provider agreement.
67:16:35:06 Medical assistance cross-over claim requirements.
67:16:35:07 Adjustment/void claims.
67:16:35:08 Requests for reimbursement -- Certification.
67:16:35:09 Use of rubber stamps for claim information.
67:16:35:10 Claim substantiation.
67:16:35:11 Repealed.
67:16:35:12 Pended claims.
67:16:35:13 Denied claims.
67:16:35:14 Remittance advice.
67:16:35:15 Claim submission and resubmission limits.
67:16:35:16 Application of chapter.
67:16:35:01. Definitions. Terms used in this chapter mean:
(1) "Adjustment/void claim form," a form that is used to adjust or void a previously paid claim;
(2) "Cross-over claim form," a form used to record the Medicare co-insurance and deductible payments for recipients who are eligible for both Medicare and Medicaid;
(3) "Denied claim," a claim that does not qualify for a medical assistance payment;
(4) "Pended claim," a claim which has not been paid or denied but is being reviewed for final action; and
(5) "Remittance advice," a document sent to the provider which contains the status of claims submitted by that provider.
Source: 17 SDR 4, effective July 16, 1990; 17 SDR 184, effective June 6, 1991; 26 SDR 168, effective July 1, 2000.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:16:35:02. Verification of eligibility before claim submitted. Before a provider submits a claim, the provider must verify an individual's eligibility for the medical assistance program by requesting the individual to produce either the individual's medical assistance identification card or a letter from the department which verifies the individual's eligibility. The provider must verify and record the recipient identification as required for the claim.
Source: 17 SDR 4, effective July 16, 1990; 26 SDR 168, effective July 1, 2000.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:16:35:03. Claims limited to items and services covered under article. A provider may submit claims only for those supplies and services that the provider knows, or should have known, are covered under this article. A provider, other than a school district, may not submit claims for services to children under the age of 21, if the provider knows or should have known that the services are listed in the child's individual education plan.
The submission of a claim containing miscoding that may result in inflated reimbursement or in reimbursement for noncovered services under this article is considered abuse of the program and possible fraud and may be cause for terminating the provider agreement.
Source: 15 SDR 2, effective July 17, 1988, transferred from § 67:16:01:07.02, 17 SDR 4, effective July 16, 1990; 17 SDR 184, effective June 6, 1991; 19 SDR 26, effective August 23, 1992; 19 SDR 165, effective May 3, 1993; 49 SDR 21, effective September 12, 2022.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1(4)(6).
Cross-Reference: School districts, ch 67:16:37.
67:16:35:04. Time
limits for submission of claims. The department must receive a provider's
completed claim form within six months following the month the service was
provided. This time limit may be waived
or extended only if one or more of the following situations exist:
(1) The claim is an
adjustment or void of a previously paid claim and is received within three
months after the previously paid claim;
(2) The claim is received
within six months after a retroactive initial eligibility determination was
made as a result of an appeal;
(3) The claim is received
within three months after a previously denied claim;
(4) The claim is received
within six months after the provider receives payment from Medicare or private
health insurance or receives a notice of denial from Medicare or private health
insurance; or
(5) To correct an error
made by the department.
Source:
SL 1975, ch 16, § 1; 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7
SDR 89, effective July 1, 1981; 15 SDR 2, effective July 17, 1988; transferred
from § 67:16:01:14, 17 SDR 4, effective July 16, 1990; 19 SDR 26,
effective August 23, 1992; 37 SDR 53, effective September 23, 2010.
General
Authority: SDCL 28-6-1.
Law
Implemented: SDCL 28-6-1.
67:16:35:06. Medical assistance cross-over claim requirements. A cross-over claim may be submitted to the department if the provider's claim to Medicare did not trigger an automatic payment of the deductible or coinsurance. Proof of payment by Medicare must be attached. A cross-over claim must contain the following information:
(1) The provider's name and National Provider Identification (NPI) number and taxonomy code;
(2) The recipient's full name and medical assistance identification number from the recipient's medical assistance identification card;
(3) Third-party liability information required under chapter 67:16:26;
(4) The date of service;
(5) The place of service;
(6) The provider's usual and customary charge billed to Medicare;
(7) Units of service furnished, if more than one;
(8) The applicable procedure code from the Health Care Common Procedure Coding System (HCPCS), as adopted in § 67:16:01:27, or the Current Procedural Terminology (CPT), as adopted in § 67:16:01:25;
(9) The amount paid by Medicare plus the Medicare discount or write off amount;
(10) Proof of the deductible or co-insurance, which must be attached;
(11) The amount paid by third-party payers other than Medicare, if any;
(12) The amount originally billed to Medicare; and
(13) The type of Medicare coverage.
Source: 17 SDR 4, effective July 16, 1990; 17 SDR 184, effective June 6, 1991; 40 SDR 122, effective January 7, 2014; 43 SDR 80, effective December 5, 2016.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:16:35:07. Adjustment/void claims. A provider may have a previously paid claim adjusted or voided by completing and submitting a new claim to the Department coded as an adjustment or void. Claim forms may be submitted electronically.
Source: 17 SDR 4, effective July 16, 1990; 41 SDR 93, effective December 3, 2014.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:16:35:08. Requests for reimbursement -- Certification. The provider or the provider's representative must sign the claim as a certification of the truth and accuracy of the claim. The provider's name, not the name of the facility or business, must be signed using handwriting, typewriter, signature stamp, computer impulse, or other means utilized as a signature. Each claim must indicate the date the form was signed.
Source: 15 SDR 2, effective July 17, 1988; transferred from § 67:16:01:07.01, 17 SDR 4, effective July 16, 1990; 23 SDR 38, effective September 26, 1996.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:16:35:10. Claim substantiation. At the department's request, a provider must furnish information needed to substantiate a claim being processed, a claim being reviewed for determination of payment, or a claim under postpayment review.
Source: 17 SDR 4, effective July 16, 1990; 19 SDR 165, effective May 3, 1993.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:16:35:11. Claim forms and copies. Repealed.
Source: 17 SDR 4, effective July 16, 1990; repealed, 40 SDR 122, effective January 7, 2014.
67:16:35:12. Pended claims. The department may pend a claim for any of the following general classes of reasons:
(1) The claim was submitted with erroneous, incomplete, or missing information;
(2) The information on the claim does not match the state master recipient or provider eligibility files;
(3) The claim requires action by the department for medical review, manual pricing, individual requests, late submission exceptions, or utilization review;
(4) The department erroneously entered the claim into the data processing system;
(5) A third-party source exists;
(6) The claim is a possible duplicate of another paid claim;
(7) The claim is suspected of being false;
(8) The claim is incorrect;
(9) The claim is submitted by a provider who is currently being investigated by the Medicaid fraud unit; or
(10) The claim is submitted by a provider who is currently being reviewed or investigated by the department.
Claims pended under subdivision (9) or (10) of this section remain pended until the investigation or review is completed. Time limits for processing claims do not apply to claims pended under subdivision (9) or (10) of this section.
Source: 17 SDR 184, effective June 6, 1991; 19 SDR 165, effective May 3, 1993.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross-References:
Remittance advice, § 67:16:35:14;
Timely processing of claims -- Time limitation does not apply to claims from providers under investigation for fraud or abuse, 45 C.F.R. § 447.45(d)(4)(iii);
Payments and obligations to be authorized by law -- Liability to state for unauthorized payments, SDCL 4-8-2.
67:16:35:13. Denied claims. The department may deny a claim for any of the following reasons:
(1) The service claimed was not medically necessary;
(2) The claim is a duplicate of a prior paid claim;
(3) Third-party liability exists;
(4) The claim contains data that is logically inconsistent;
(5) The time limit for the submission of a claim has expired;
(6) The provider or recipient of service was not eligible when the service was provided;
(7) The drug is considered less than effective;
(8) The service is considered experimental;
(9) The claim contains erroneous, incomplete, or missing information;
(10) The claim is false or incorrect or violates provisions of this article; or
(11) The service is incidental to or an integral part of an allowable service.
Source: 17 SDR 184, effective June 6, 1991; 19 SDR 165, effective May 3, 1993.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross Reference: Payments and obligations to be authorized by law -- Liability to state for unauthorized payments, SDCL 4-8-2.
67:16:35:14. Remittance advice. The provider must reconcile the remittance advice with the patient's records. The department shall send a warrant with the remittance advice when the amount of a check is indicated on the remittance advice. The provider must retain the remittance advice according to § 67:16:34:05. Claims to be resubmitted for payment must meet the requirements of § 67:16:35:15.
When the department denies or pends a claim, the remittance advice shall contain the specific reason the claim was denied or pended.
Source: 17 SDR 184, effective June 6, 1991; 19 SDR 165, effective May 3, 1993.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross-Reference: Pended claims, § 67:16:35:12.
67:16:35:15. Claim submission and resubmission limits. 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.
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.
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.
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.
Source: 17 SDR 184, effective June 6, 1991; 19 SDR 165, effective May 3, 1993.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross-Reference: Duration of agreement, § 67:16:33:04.
