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Download Rule 67:16:35:13 in Microsoft Word Format Printer Friendly

          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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