<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.sf8553829-a811-457b-8d73-d3fa9f36e90fP0 { 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.sf8553829-a811-457b-8d73-d3fa9f36e90fC0 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sf8553829-a811-457b-8d73-d3fa9f36e90fC0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sf8553829-a811-457b-8d73-d3fa9f36e90fC0-000001 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sf8553829-a811-457b-8d73-d3fa9f36e90f000002 { background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sf8553829-a811-457b-8d73-d3fa9f36e90fC0-000003 { 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="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:35:06"><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0-000000">67:16:35:06</span></a><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0-000001">.  Medical assistance cross-over claim requirements.</span><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0"> A cross-over claim may be submitted to the department if the provider's claim to </span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">m</span><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">edicare did not trigger an automatic payment of the deductible or coinsurance. Proof of payment by </span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">m</span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">edicare must be attached</span><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0"> to the claim</span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">. A cross-over claim must contain the following information:</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90f000002"> </span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (1)  The provider's name and National Provider Identification number and taxonomy code;</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (2)  The recipient's full name and medical assistance identification number from the recipient's medical assistance identification card;</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (3)  Third-party liability information required under chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:26"><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0-000003">67:16:26</span></a><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">;</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (4)  The date of service;</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (5)  The place of service;</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (6)  The provider's usual and customary charge billed to </span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">m</span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">edicare;</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (7)  Units of service furnished, if more than one;</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (8)  The applicable procedure code;</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (9)  The amount paid by </span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">m</span><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">edicare plus the </span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">m</span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">edicare discount or write off amount;</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (10)  Proof of the deductible or co-insurance, which must be attached;</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (11)  The amount paid by third-party payers other than </span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">m</span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">edicare, if any;</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (12)  The amount originally billed to </span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">m</span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">edicare; and</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    (13)  The type of </span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">m</span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">edicare coverage.</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90f000002"> </span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    </span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0-000001">Source:</span><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0"> 17 SDR 4, effective July 16, 1990; 17 SDR 184, effective June 6, 1991; 40 SDR 122, effective January 7, 2014</span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">; 43 SDR 80, effective December 5, 2016; 52 SDR 126, effective July 1, 2026</span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">.</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    </span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0-000001">General Authority:</span><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0-000003">28-6-1</span></a><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">.</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">    </span><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0-000001">Law Implemented:</span><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0-000003">28-6-1</span></a><span class="sf8553829-a811-457b-8d73-d3fa9f36e90fC0">.</span></p><p dir="ltr" class="sf8553829-a811-457b-8d73-d3fa9f36e90fP0"><span xml:space="preserve" class="sf8553829-a811-457b-8d73-d3fa9f36e90f000002"> </span></p></div></body></html>