<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.sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0 { 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.sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31e000002 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0-000003 { 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="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:45:02:12"><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0-000000">67:45:02:12</span></a><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0-000001">.  Claim requirements.</span><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0"> A claim for services provided under this chapter must be submitted on </span><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">a</span><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0"> form or in an electronic format that contains the following:</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31e000002"> </span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    (1)  The </span><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">service </span><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">recipient's full name;</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    (2)  The recipient's medical assistance identification number from the recipient's medical assistance identification card;</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    (3)  Third-party liability information as required under chapter </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:26"><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0-000003">67:16:26</span></a><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">;</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    (4)  Beginning and end dates of service. A provider may only bill for one month at a time;</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    (5)  The number of covered days;</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    (6)  The total charges;</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    (7)  The type of bill;</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    (8)  The provider's name, address, telephone number, and National Provider Identification number;</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    (9)  The applicable diagnosis codes;</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    (10)  The patient status code indicating the patient's status on the final day of service of the billing period; and</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    (11)  The revenue code identifying the specific accommodation, ancillary service, or billing calculation.</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31e000002"> </span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    A separate claim form must be submitted for each recipient.</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31e000002"> </span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    </span><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0-000001">Source:</span><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0"> 17 SDR 4, effective July 16, 1990; transferred from § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:04:31"><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0-000003">67:16:04:31</span></a><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">, 18 SDR 67, effective October 13, 1991; 40 SDR 122, effective January 7, 2014; 42 SDR 51, effective October 13, 2015</span><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">; 52 SDR 126, effective July 1, 2026</span><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">.</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    </span><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0-000001">General Authority:</span><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0-000003">28-6-1</span></a><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">.</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">    </span><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0-000001">Law Implemented:</span><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0-000003">28-6-1</span></a><span class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eC0">.</span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31e000002"> </span></p><p dir="ltr" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31eP0"><span xml:space="preserve" class="sf841bd05-1fdb-49ab-a3d5-6c26cc6ba31e000002"> </span></p></div></body></html>