<html> <head> <title>Rule 67:16:26:07.02 Certain claims eligible for payment before third-party benefits recovered -- Department to pursue reimbursement.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:26:07.02"> <META NAME="Description" Content="Administrative Rules 67:16:26:07.02 Certain claims eligible for payment before third-party benefits recovered -- Department to pursue reimbursement."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 15 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:"Cambria Math"; panose-1:2 4 5 3 5 4 6 3 2 4;} @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:10.0pt; font-family:"Times",serif;} a:link, span.MsoHyperlink {color:blue; text-decoration:underline;} a:visited, span.MsoHyperlinkFollowed {color:purple; text-decoration:underline;} .MsoChpDefault {font-size:10.0pt;} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US link=blue vlink=purple> <div class=WordSection1> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:26:07.02.&nbsp;&nbsp;Certain claims eligible for payment before third-party benefits recovered -- Department to pursue reimbursement.</b> A provider is eligible to receive payment for the full amount allowed under the department's payment schedule while the department pursues reimbursement from third-party sources in the following situations:</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;The claim is for services for early and periodic screening, diagnosis, and treatment</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> provided under chapter 67:16:11, except for psychiatric inpatient services, nutritional therapy, nutritional supplements, and electrolyte replacements;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>2</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>)&nbsp;&nbsp;The third-party liability is derived from an absent parent whose obligation to pay support is being enforced by the department</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> and 100 days from the date of service have elapsed</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>3</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>)&nbsp;&nbsp;The probable existence of third-party liability cannot be established at the time the claim is filed;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>4</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>)&nbsp;&nbsp;The claim is for nursing facility services reimbursed under chapter 67:16:04; or</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>5</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>)&nbsp;&nbsp;The claim is for services provided by a school district under chapter 67:16:37.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 16 SDR 226, effective June 24, 1990; 17 SDR 184, effective June 6, 1991; 31 SDR 39, effective September 29, 2004; 46 SDR 50, effective October 10, 2019; 47 SDR 38, effective October 6, 2020.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&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></span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&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></span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>(2)(4)</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Cross-Reference:</b> Pay and chase provisions, 42 C.F.R. &#167;&nbsp;433.139.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> </div> </body> </html>