<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.s3363b842-663d-41b8-a7de-497195092189P0 { 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.s3363b842-663d-41b8-a7de-497195092189C0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s3363b842-663d-41b8-a7de-497195092189C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s3363b842-663d-41b8-a7de-497195092189C0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s3363b842-663d-41b8-a7de-497195092189000002 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s3363b842-663d-41b8-a7de-497195092189C0-000003 { 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="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:41:13"><span class="s3363b842-663d-41b8-a7de-497195092189C0-000000">67:16:41:13</span></a><span class="s3363b842-663d-41b8-a7de-497195092189C0-000001">.  Claim requirements.</span><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0"> A claim for services provided under this chapter must be submitted on a form </span><span class="s3363b842-663d-41b8-a7de-497195092189C0">that</span><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0"> contains the following information:</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189000002"> </span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    (1)  The </span><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">service </span><span class="s3363b842-663d-41b8-a7de-497195092189C0">recipient's full name;</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    (2)  The recipient's medical assistance identification number from the recipient's medical identification card;</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    (3)  Third-party liability information required under chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:26"><span class="s3363b842-663d-41b8-a7de-497195092189C0-000003">67:16:26</span></a><span class="s3363b842-663d-41b8-a7de-497195092189C0">;</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    (4)  Date of service;</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    (5)  Place of service;</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    (6)  The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing from this charge;</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    (7)  Units of service furnished, if more than one;</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    (8)  The applicable procedure codes contained in §</span><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0"> </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:41:09"><span class="s3363b842-663d-41b8-a7de-497195092189C0-000003">67:16:41:09</span></a><span class="s3363b842-663d-41b8-a7de-497195092189C0">;</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    (9)  The applicable diagnosis codes;</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    (10)  The provider's name and National Provider Identification number; and</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    (11)  Type of service provided.</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189000002"> </span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    </span><span class="s3363b842-663d-41b8-a7de-497195092189C0-000001">Source:</span><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0"> 22 SDR 6, effective July 26, 1995; 40 SDR 122, effective January 7, 2014; 42 SDR 51, effective October 13, 2015</span><span class="s3363b842-663d-41b8-a7de-497195092189C0">; 52 SDR 126, effective July 1, 2026</span><span class="s3363b842-663d-41b8-a7de-497195092189C0">.</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    </span><span class="s3363b842-663d-41b8-a7de-497195092189C0-000001">General Authority:</span><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s3363b842-663d-41b8-a7de-497195092189C0-000003">28-6-1</span></a><span class="s3363b842-663d-41b8-a7de-497195092189C0">.</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    </span><span class="s3363b842-663d-41b8-a7de-497195092189C0-000001">Law Implemented:</span><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s3363b842-663d-41b8-a7de-497195092189C0-000003">28-6-1</span></a><span class="s3363b842-663d-41b8-a7de-497195092189C0">.</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189000002"> </span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    </span><span class="s3363b842-663d-41b8-a7de-497195092189C0-000001">Cross-Reference:</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0">    </span><span class="s3363b842-663d-41b8-a7de-497195092189C0">Claims, ch</span><span class="s3363b842-663d-41b8-a7de-497195092189C0">apter</span><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189C0"> </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:35"><span class="s3363b842-663d-41b8-a7de-497195092189C0-000003">67:16:35</span></a><span class="s3363b842-663d-41b8-a7de-497195092189C0">.</span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189000002"> </span></p><p dir="ltr" class="s3363b842-663d-41b8-a7de-497195092189P0"><span xml:space="preserve" class="s3363b842-663d-41b8-a7de-497195092189000002"> </span></p></div></body></html>