<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.s3ab4155c-3b3a-40df-bc5b-792360e93803P0 { 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.s3ab4155c-3b3a-40df-bc5b-792360e93803C0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s3ab4155c-3b3a-40df-bc5b-792360e93803C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s3ab4155c-3b3a-40df-bc5b-792360e93803C0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s3ab4155c-3b3a-40df-bc5b-792360e93803C0-000002 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s3ab4155c-3b3a-40df-bc5b-792360e93803000003 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s3ab4155c-3b3a-40df-bc5b-792360e93803P1 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: justify; background: white; font-family: Times; font-size: 12pt; line-height: 108%; } </style></head><body><div><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=44:66:02:03"><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0-000000">44:66:02:03</span></a><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0-000001">.  Required patient data to be reported.</span><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0"> Each hospital required to report </span><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">charge information </span><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">pursuant to </span><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=34-12E-11"><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0-000002">34-12E-11</span></a><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0"> shall provide the following information from the UB-04 form:</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803000003"> </span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    (1)  Record type;</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    (2)  Hospital number;</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    (3)  Patient control number;</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    (4)  Date of birth;</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    (5)  Sex;</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    (6)  Admission date;</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    (7)  Principal diagnosis;</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    (8)  Admitting diagnosis;</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    (9)  Principal procedure;</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    (10)  Discharge date;</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    (11)  Patient status; and</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    (12)  Total charges.</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803000003"> </span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    </span><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">For the purposes of this section, "UB-04 form" is a standardized form from the Centers for Medicare and Medicaid Services used to electronically submit claims for health care received in an institutional setting</span><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">.</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803000003"> </span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    </span><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0-000001">Source:</span><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0"> 32 SDR 69, effective November 7, 2005; 34 SDR 88, effective September 10, 2007; 35 SDR 183, effective February 2, 2009</span><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">; 52 SDR 41, effective October 27, 2025</span><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">.</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P1"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    </span><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0-000001">General Authority:</span><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=34-12E-11"><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0-000002">34-12E-11</span></a><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">.</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">    </span><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0-000001">Law Implemented:</span><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=34-12E-11"><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0-000002">34-12E-11</span></a><span class="s3ab4155c-3b3a-40df-bc5b-792360e93803C0">.</span></p><p dir="ltr" class="s3ab4155c-3b3a-40df-bc5b-792360e93803P0"><span xml:space="preserve" class="s3ab4155c-3b3a-40df-bc5b-792360e93803000003"> </span></p></div></body></html>