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.
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