<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.s09c19e3d-987e-4428-b87c-077fd42d6eecP0 { 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.s09c19e3d-987e-4428-b87c-077fd42d6eecC0 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000001 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s09c19e3d-987e-4428-b87c-077fd42d6eec000002 { background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000003 { 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="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:28:10"><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000000">67:16:28:10</span></a><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000001">.  Claim requirements.</span><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0"> A claim for services provided under this chapter must be submitted on a form </span><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">that</span><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0"> contains the following information:</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eec000002"> </span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    (1)  The </span><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">service </span><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">recipient's full name;</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    (2)  The recipient's medical assistance identification number from the recipient's medical assistance identification card;</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    (3)  Third-party liability information required under chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:26"><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000003">67:16:26</span></a><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">;</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    (4)  Date of service;</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    (5)  Place of service;</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    (6)  The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge;</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    (7)  The applicable procedure codes</span><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0"> </span><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">for services covered under § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:28:04"><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000003">67:16:28:04</span></a><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">;</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    (8)  The units of service furnished, if more than one; and</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    (9)  The provider's name and medical assistance identification number.</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eec000002"> </span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    A separate claim form must be used for each recipient.</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eec000002"> </span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    </span><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000001">Source:</span><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0"> 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; 34 SDR 68, effective September 12, 2007</span><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">; 43 SDR 80, effective December 5, 2016; 52 SDR 126, effective July 1, 2026</span><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">.</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    </span><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000001">General Authority:</span><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000003">28-6-1</span></a><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">.</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    </span><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000001">Law Implemented:</span><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000003">28-6-1</span></a><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">.</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eec000002"> </span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">    </span><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000001">Cross-Reference:</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000001">    </span><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">Claims, ch</span><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">apter</span><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0"> </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:35"><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0-000003">67:16:35</span></a><span class="s09c19e3d-987e-4428-b87c-077fd42d6eecC0">.</span></p><p dir="ltr" class="s09c19e3d-987e-4428-b87c-077fd42d6eecP0"><span xml:space="preserve" class="s09c19e3d-987e-4428-b87c-077fd42d6eec000002"> </span></p></div></body></html>