<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.sa541f95b-76fc-404c-91ea-cd98e217d052P0 { 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.sa541f95b-76fc-404c-91ea-cd98e217d052C0 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sa541f95b-76fc-404c-91ea-cd98e217d052C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sa541f95b-76fc-404c-91ea-cd98e217d052C0-000001 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sa541f95b-76fc-404c-91ea-cd98e217d052000002 { background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sa541f95b-76fc-404c-91ea-cd98e217d052C0-000003 { 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="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:48:13"><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000000">67</span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000000">:</span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000000">16</span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000000">:</span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000000">48</span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000000">:</span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000000">13</span></a><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000001">.  Claim requirements -- Substance use disorders.</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0"> A claim for a substance</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0"> </span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">use disorder treatment service provided under this chapter </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">must</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0"> be submitted to the department</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0"> </span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">on a form or in an electronic format and </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">must</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0"> contain the following information:</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052000002"> </span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    (1)</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">  </span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">The </span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">service </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">recipient's full name;</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    (2)</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">  </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">The recipient's medical assistance identification number from the recipient's medical</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0"> </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">assistance identification card;</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    (3)</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">  </span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">Third-party liability information required under chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:26"><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000003">67:16:26</span></a><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">;</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    (4)</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">  </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">Date of service;</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    (5)</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">  </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">Place of service;</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    (6)</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">  </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">The provider's usual and customary charge. The provider may not subtract other third</span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">-p</span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">arty</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0"> </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">or cost-sharing payments from this charge;</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    (7)</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">  </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">The applicable procedure codes for the covered services provided;</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    (8)</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">  </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">The applicable diagnosis codes;</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    (9)</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">  </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">The units or days of service furnished, if more than one;</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    (10)</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">  </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">The provider's name and National Provider Identification number; and</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    (11)</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">  </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">The prior authorization number issued to the provider by the division for services that</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0"> </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">require prior authorization.</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052000002"> </span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    A separate claim form must be used for each recipient.</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052000002"> </span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000001">Source:</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0"> </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">43</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0"> SDR </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">80</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">, effective </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">December 5, 2016; 52 SDR 126, effective July 1, 2026.</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000001">General Authority:</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000003">28-6-1</span></a><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">.</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    </span><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000001">Law Implemented:</span><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0-000003">28-6-1</span></a><span class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">.</span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052000002"> </span></p><p dir="ltr" class="sa541f95b-76fc-404c-91ea-cd98e217d052P0"><span xml:space="preserve" class="sa541f95b-76fc-404c-91ea-cd98e217d052C0">    </span></p></div></body></html>