<html> <head> <title>Rule 67:16:24:06 Claim requirements.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:24:06"> <META NAME="Description" Content="Administrative Rules 67:16:24:06 Claim requirements."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:24:06.&nbsp;&nbsp;Claim requirements.</b> A claim for services provided under this chapter must be submitted on a form available from the department or the claim may be electronically transmitted through a system approved by the department. The claim must contain the following information:</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;The recipient's full name;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;The recipient's medical assistance identification number from the recipient's medical assistance identification card;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;Date of service;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (4)&nbsp;&nbsp;As specified in the provider's contract with the department, the provider's rate of payment for the service provided;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (5)&nbsp;&nbsp;The units of service furnished, if more than one; and</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (6)&nbsp;&nbsp;The provider's name and medical assistance identification number.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; A separate claim form must be used for each recipient.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 4, effective July 16, 1990; 17 SDR 22, effective August 14, 1990; 18 SDR 78, effective November 4, 1991; 19 SDR 26, effective August 23, 1992; 19 SDR 165, effective May 3, 1993; 20 SDR 149, effective March 21, 1994; 21 SDR 183, effective April 30, 1995; 28 SDR 96, effective December 30, 2001.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Cross-Reference:</b> Claims, ch 67:16:35.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html>