67:16:41:14.  Billing requirements. The following requirements apply to services billed under this chapter:

    (1)  Each claim must contain the medical assistance provider identification number of the individual delivering the service;

    (2)  A claim may not be submitted for a diagnostic assessment that exceeds four hours, unless there has been a break of at least 12 months in the delivery of mental health treatment to the recipient;

    (3)  A claim may not be submitted for a diagnostic assessment until the assessment is completed and recorded in the recipient's clinical record;

    (4)  A claim may not be submitted for mental health treatment provided before the diagnostic assessment is completed, except for treatment provided with a provisional diagnosis of a mental health disorder during the 30-day time period the mental health provider has to complete the diagnostic assessment;

    (5)  A claim may not be submitted for mental health services provided after the fourth face-to-face or telehealth session with the recipient and before the effective date of the treatment plan;

    (6)  If a psychotherapy session is provided to more than one individual, the service must be billed as family or group psychotherapy, whichever is appropriate, even if the individual is the only one eligible for the medical assistance program;

    (7)  If a recipient is involved in a psychotherapy session only as part of a family or group session for the treatment of another family member who is a mental health client, a claim for the session may not be submitted for that recipient;

    (8)  Except for a psychiatric diagnostic interview examination and a diagnostic assessment, a claim may not be submitted for mental health treatment, unless the recipient has a primary diagnosis of a mental health disorder; and

    (9)  A claim may be submitted for each eligible recipient who is in a family or group psychotherapy session and is actively receiving psychotherapy, if each family or group member for whom services are billed to the medical assistance program has a complete clinical record that meets the requirements of § 67:16:41:08.

    A provider shall submit claims at the provider's usual and customary charge. A claim may contain only those procedure codes listed on the department's fee schedule website.

    Source: 22 SDR 6, effective July 26, 1995; 26 SDR 168, effective July 1, 2000; 37 SDR 53, effective September 23, 2010; 46 SDR 50, effective October 10, 2019; 48 SDR 39, effective October 3, 2021; 49 SDR 21, effective September 12, 2022.

    General Authority: SDCL 28-6-1.

    Law Implemented: SDCL 28-6-1(1)(2).