<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.s09657546-6d65-4fc8-ba1d-8473d69d2713P0 { 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.s09657546-6d65-4fc8-ba1d-8473d69d2713C0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s09657546-6d65-4fc8-ba1d-8473d69d2713C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s09657546-6d65-4fc8-ba1d-8473d69d2713C0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s09657546-6d65-4fc8-ba1d-8473d69d2713000002 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s09657546-6d65-4fc8-ba1d-8473d69d2713C0-000003 { 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="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:43:09"><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0-000000">67:16:43:09</span></a><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0-000001">.  Claim requirements.</span><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0"> A claim for services provided under this chapter must be submitted on a form </span><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">that</span><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0"> contains the following information:</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713000002"> </span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    (1)  The child's full name;</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    (2)  The child's medical assistance identification number from the child's medical identification card;</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    (3)  Third-party liability information required under chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:26"><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0-000003">67:16:26</span></a><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">;</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    (4)  Date of service;</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    (5)  The provider's current daily rate. The provider may not subtract other third-party or cost-sharing from this charge;</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    (6)  Units of service furnished, if more than one;</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    (7)  The applicable diagnosis codes;</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    (8)  The provider's name and National Provider Identification number;</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    (9)  Type of admission;</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    (10)  The prior authorization number assigned by the care manager;</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    (11)  The revenue code; and</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    (12)  The type of bill.</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713000002"> </span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    </span><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0-000001">Source:</span><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0"> 23 SDR 2, effective July 15, 1996; 42 SDR 51, effective October 13, 2015</span><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">; 52 SDR 126, effective July 1, 2026</span><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">.</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    </span><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0-000001">General Authority:</span><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0-000003">28-6-1</span></a><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">.</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">    </span><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0-000001">Law Implemented:</span><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0-000003">28-6-1</span></a><span class="s09657546-6d65-4fc8-ba1d-8473d69d2713C0">.</span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713000002"> </span></p><p dir="ltr" class="s09657546-6d65-4fc8-ba1d-8473d69d2713P0"><span xml:space="preserve" class="s09657546-6d65-4fc8-ba1d-8473d69d2713000002"> </span></p></div></body></html>