<html> <head> <title>Rule 20:06:27:04 Requirements for use of HCFA Form 1450.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:27:04"> <META NAME="Description" Content="Administrative Rules 20:06:27:04 Requirements for use of HCFA Form 1450."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} @font-face {font-family:Times; panose-1:0 0 0 0 0 0 0 0 0 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:10.0pt; font-family:Times;} /* Page Definitions */ @page WordSection1 {size:8.5in 11.0in; margin:49.7pt 63.35pt 49.7pt 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='text-align:justify'><a name="_GoBack"></a><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>20:06:27:04.&nbsp;&nbsp;Requirements for use of HCFA Form 1450.</b> The HCFA Form 1450 shall be used as follows:</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;Institutional care practitioners shall use the HCFA Form UB-92 HCFA-1450, adopted by HCFA and in effect as of June 30, 1995, when filing claims for health care services with issuers. When requested by the patient, institutional care providers that bill patients directly shall provide a completed HCFA Form 1450 in addition to any other explanation or information used to bill the patient;</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; (2)&nbsp;&nbsp;Issuers may require institutional care practitioners to use only the following coding system for the initial filing of claims for health care services:</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;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (a)&nbsp;&nbsp;ICD-9-CM codes, in effect as of June 30, 1995;</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;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (b)&nbsp;&nbsp;Revenue codes, in effect as of June 30, 1995;</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;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (c)&nbsp;&nbsp;HCPCS Level 1, Level 2, and Level 3 codes, in effect as of June 30, 1995; and</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;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (d)&nbsp;&nbsp;The information outlined in subdivision 20:06:27:03(3), if the charges include direct service furnished by a health care practitioner and the direct service is not covered by the instructions for the HCFA Form 1450;</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; (3)&nbsp;&nbsp;Hospitals may use the HCFA Form 1500 to supplement a HCFA Form 1450 if necessary in billing patients or their representatives or filing claims with issuers for outpatient services.</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> 22 SDR 97, effective December 18, 1995; 42 SDR 52, effective October 13, 2015.</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=58-12-14">58-12-14.</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=58-12-12">58-12-12.</A></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>References:</b> <b>HCFA Form 1450: UB-92 HCFA-1450</b>, in effect as of June 30, 1995, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: Carton of 1,000, $67.95.</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>The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)</b>, Fourth Edition, Volumes I and II, 1995; Context Software Systems, Inc., McGraw-Hill, Inc. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: $39.95 each, plus shipping and handling.</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>Revenue Codes: UB-92, National Uniform Billing Data Element Specifications</b> as Developed by the National Uniform Billing Committee as of January 8, 1993, effective October 1, 1993, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the South Dakota Division of Insurance, 124 South Euclid Avenue, 2<sup>nd</sup> floor, Pierre, SD 57501-5070. Cost: $.75 a page.</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>HCPCS Level 1 Codes: Physicians' Current Procedural Terminology (CPT 95)</b>, Fourth edition, revised 1994, American Medical Association. Copies may be obtained from American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: $41.95 each, plus shipping and handling.</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>Level 2 HCPCS Code: HCFA Common Procedure Coding System (HCPCS), (Alpha-Numeric Portion)</b>, in effect as of January, 1995, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from Superintendent of Documents, Publication Service Section 5505, Washington, DC 20402. Cost: $16 each.</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>Level 3 HCPCS Code</b>: HCPCS 1995, November 7, 1994, pp. 161-163. Denver Region VIII, 00820 North Dakota B/S, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the South Dakota Division of Insurance, 124 South Euclid Avenue, 2<sup>nd</sup> Floor, Pierre, SD 57501-5070. Cost: $.75 a page.</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>