67:16:41:13.  Claim requirements. A claim for services provided under this chapter must be submitted on a form which contains the following information:

 

          (1)  The recipient's full name;

          (2)  The recipient's medical assistance identification number from the recipient's medical 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 or cost-sharing from this charge;

          (7)  Units of service furnished, if more than one;

          (8)  The applicable procedure codes contained in § 67:16:41:09;

          (9)  The applicable diagnosis codes adopted in § 67:16:01:26;

          (10)  The provider's name and National Provider Identification (NPI) number; and

          (11)  Type of service provided.

 

          Source: 22 SDR 6, effective July 26, 1995; 40 SDR 122, effective January 7, 2014; 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.