<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.s17a36da3-e979-4e99-8d1b-06dd66af0023P0 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: justify; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; } span.s17a36da3-e979-4e99-8d1b-06dd66af0023C0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s17a36da3-e979-4e99-8d1b-06dd66af0023000002 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:39:13"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000000">67:16:39:13</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000001">.  Billing requirements.</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> Claims submitted under this chapter must meet the following </span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">billing </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">requirements:</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023000002"> </span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (1)  Physician services must follow the billing requirements contained in chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:02"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:02</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">;</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (2)  Inpatient</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> and </span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">outpatient hospital services must follow the billing requirements contained in chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:03"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:03</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">;</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (3)  Home health services must follow the billing requirements contained in chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:05"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:05</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">;</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (4)  Screening services must follow the billing requirements contained in chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:11"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:11</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">;</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (5)  Clinic services must follow the billing requirements contained in chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:13"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:13</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">;</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (6)  Ambulatory surgical center services must follow the billing requirements contained in chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:28"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:28</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">;</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (7)  Medical equipment services must follow the billing requirements contained in chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:29"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:29</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">;</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (8)  Organ transplant services must follow the billing requirements contained in chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:31"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:31</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">;</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (9)  School district services must follow the billing requirements contained in chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:37"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:37</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">;</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (10)  Mental health services provided by independent practitioners must follow the billing requirements contained in chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:41"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:41</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">;</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (11)  Federally qualified health center and rural health clinic services must follow the billing requirements </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">contained in</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:44"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:44</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">;</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (12)  Diabetes </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">self-management training</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> must follow the billing requirements </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">contained in</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:46"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:46</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">; and</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    (13)  </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">Substance use disorder</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> treatment services must follow the billing requirements contained in chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:48"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:</span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">16</span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">:</span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">4</span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">8</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">.</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023000002"> </span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    A provider may not</span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">,</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> on behalf of a recipient</span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">, submit a claim</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> for services provided under this chapter unless the provider is the recipient's </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">primary care provider</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> or the covered service was provided as a result of a referral and authorization by the recipient's </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">primary care provider</span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">.</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023000002"> </span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    If a recipient's primary care provider </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">submits</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> a claim for covered services, the claim must contain the </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">primary care provider's</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">National Provider Identifier</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> number. If a provider </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">submits</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> a claim for covered services provided as a result of a referral and authorization by the recipient's </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">primary care provider</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">, the claim must contain the provider's </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">National Provider Identifier</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> number</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> and</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> the </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">National Provider Identifier</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> number of the recipient's </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">primary care provider.</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023000002"> </span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    A claim submitted without the required </span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">National Provider Identifier </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">number is cause for denial by the department.</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023000002"> </span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000001">Source:</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> 20 SDR 135, effective February 22, 1994; 26 SDR 168, effective July 1, 2000; 30 SDR 115, effective February 4, 2004; 35 SDR 88, effective October 23, 2008; 46 SDR 50, effective October 10, 2019</span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">; 49 SDR 21, effective September 12, 2022</span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">.</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000001">General Authority:</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">28-6-1</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">.</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000001">Law Implemented:</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">28-6-1</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">(1)(2)(4)</span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">.</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023000002"> </span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">    </span><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000001">Cross-Reference:</span><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0"> Records, ch </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:34"><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0-000003">67:16:34</span></a><span class="s17a36da3-e979-4e99-8d1b-06dd66af0023C0">.</span></p><p dir="ltr" class="s17a36da3-e979-4e99-8d1b-06dd66af0023P0"><span xml:space="preserve" class="s17a36da3-e979-4e99-8d1b-06dd66af0023000002"> </span></p></div></body></html>