<html> <head> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <style> <!-- --> </style> </head> <body lang=EN-US link=blue vlink="#954F72"> <div> <p align=center><b>CHAPTER 67:16:35</b></p> <p align=center><b>CLAIMS</b></p> <p>Section</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:01">67:16:35:01</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Definitions.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:02">67:16:35:02</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Verification of eligibility before claim submitted.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:03">67:16:35:03</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Claims limited to items and services covered under article.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:04">67:16:35:04</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Time limits for submission of claims.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:05">67:16:35:05</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Electronic media provider agreement.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:06">67:16:35:06</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Medical assistance cross-over claim requirements.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:07">67:16:35:07</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Adjustment/void claims.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:08">67:16:35:08</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Requests for reimbursement -- Certification.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:09">67:16:35:09</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Use of rubber stamps for claim information.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:10">67:16:35:10</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Claim substantiation.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:11">67:16:35:11</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Repealed.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:12">67:16:35:12</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Pended claims.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:13">67:16:35:13</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Denied claims.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:14">67:16:35:14</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Remittance advice.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:15">67:16:35:15</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Claim submission and resubmission limits.</p> <p><a href="DisplayRule.aspx?Rule=67:16:35:16">67:16:35:16</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Application of chapter.</p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:01 Definitions.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:01"> <META NAME="Description" Content="Administrative Rules 67:16:35:01 Definitions."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:01.&nbsp;&nbsp;Definitions.</b> Terms used in this chapter mean:</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;&quot;Adjustment/void claim form,&quot; a form that is used to adjust or void a previously paid claim;</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;&quot;Cross-over claim form,&quot; a form used to record the Medicare co-insurance and deductible payments for recipients who are eligible for both Medicare and Medicaid;</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;&quot;Denied claim,&quot; a claim that does not qualify for a medical assistance payment;</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (4)&nbsp;&nbsp;&quot;Pended claim,&quot; a claim which has not been paid or denied but is being reviewed for final action; and</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (5)&nbsp;&nbsp;&quot;Remittance advice,&quot; a document sent to the provider which contains the status of claims submitted by that provider.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 4, effective July 16, 1990; 17 SDR 184, effective June 6, 1991; 26 SDR 168, effective July 1, 2000.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:02 Verification of eligibility before claim submitted.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:02"> <META NAME="Description" Content="Administrative Rules 67:16:35:02 Verification of eligibility before claim submitted."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:02.&nbsp;&nbsp;Verification of eligibility before claim submitted.</b> Before a provider submits a claim, the provider must verify an individual's eligibility for the medical assistance program by requesting the individual to produce either the individual's medical assistance identification card or a letter from the department which verifies the individual's eligibility. The provider must verify and record the recipient identification as required for the claim.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 4, effective July 16, 1990; 26 SDR 168, effective July 1, 2000.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html> <br /><hr><br /><html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>p.s6ffaec41-1980-4720-a22c-6a8e88f7bdc9P0 { 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.s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s6ffaec41-1980-4720-a22c-6a8e88f7bdc9000002 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000003 { 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="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9P0"><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:35:03"><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000000">67:16:35:03</span></a><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000001">.  Claims limited to items and services covered under article.</span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0"> A provider may submit claims </span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">only </span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">for those supplies and services </span><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">that</span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0"> the provider knows, or should have known, are covered under this article. A provider</span><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">,</span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0"> other than a school district</span><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">,</span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0"> may not submit claims for services to children under </span><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">the age of 21,</span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0"> </span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">if </span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">the provider knows or should have known </span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">that the services </span><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">are listed in the child's individual education plan.</span></p><p dir="ltr" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9P0"><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9000002"> </span></p><p dir="ltr" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9P0"><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">    The submission of a claim containing miscoding that may result in inflated reimbursement or in reimbursement for noncovered services under this article is considered abuse of the program and possible fraud and may be cause for terminating the provider agreement.</span></p><p dir="ltr" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9P0"><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9000002"> </span></p><p dir="ltr" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9P0"><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">    </span><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000001">Source:</span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0"> 15 SDR 2, effective July 17, 1988, transferred from § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:01:07.02"><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000003">67:16:01:07.02</span></a><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">, 17 SDR 4, effective July 16, 1990; 17 SDR 184, effective June 6, 1991; 19 SDR 26, effective August 23, 1992; 19 SDR 165, effective May 3, 1993</span><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">; 49 SDR 21, effective September 12, 2022</span><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">.</span></p><p dir="ltr" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9P0"><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">    </span><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000001">General Authority:</span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000003">28-6-1</span></a><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">.</span></p><p dir="ltr" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9P0"><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">    </span><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000001">Law Implemented:</span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000003">28-6-1</span></a><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">(4)(6)</span><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">.</span></p><p dir="ltr" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9P0"><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9000002"> </span></p><p dir="ltr" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9P0"><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">    </span><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000001">Cross-Reference:</span><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0"> School districts, ch </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:37"><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0-000003">67:16:37</span></a><span style="white-space: pre-wrap;" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9C0">.</span></p><p dir="ltr" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9P0"><span style="white-space: pre-wrap;" xml:space="preserve" class="s6ffaec41-1980-4720-a22c-6a8e88f7bdc9000002"> </span></p></div></body></html><br /><hr><br /><html xmlns:v="urn:schemas-microsoft-com:vml" xmlns:o="urn:schemas-microsoft-com:office:office" xmlns:w="urn:schemas-microsoft-com:office:word" xmlns="http://www.w3.org/TR/REC-html40"> <head> <title>Rule 67:16:35:04 Time limits for submission of claims.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:04"> <META NAME="Description" Content="Administrative Rules 67:16:35:04 Time limits for submission of claims."> <meta http-equiv=Content-Type content="text/html; 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mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:Calibri;} </style> <![endif]--><!--[if gte mso 9]><xml> <o:shapedefaults v:ext="edit" spidmax="2050"/> </xml><![endif]--><!--[if gte mso 9]><xml> <o:shapelayout v:ext="edit"> <o:idmap v:ext="edit" data="1"/> </o:shapelayout></xml><![endif]--> </head> <body lang=EN-US style='tab-interval:.5in'> <div class=Section1> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>67:16:35:04.&nbsp;&nbsp;Time limits for submission of claims.</b> The department must receive a provider's completed claim form within six months following the month the service was provided.<span style='mso-spacerun:yes'>&nbsp; </span>This time limit may be waived or extended only if one or more of the following situations exist:<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(1)&nbsp;&nbsp;The claim is an adjustment or void of a previously paid claim and is received within three months after the previously paid claim;<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(2)&nbsp;&nbsp;The claim is received within six months after a retroactive initial eligibility determination was made as a result of an appeal;<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(3)&nbsp;&nbsp;The claim is received within three months after a previously denied claim;<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(4)&nbsp;&nbsp;The claim is received within six months after the provider receives payment from Medicare or private health insurance or receives a notice of denial from Medicare or private health insurance; or<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(5)&nbsp;&nbsp;To correct an error made by the department.<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>Source:</b> SL 1975, ch 16, &#167;&nbsp;1; 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 15 SDR 2, effective July 17, 1988; transferred from &#167;&nbsp;67:16:01:14, 17 SDR 4, effective July 16, 1990; 19 SDR 26, effective August 23, 1992; 37 SDR 53, effective September 23, 2010.<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A><o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A><o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:05 Electronic media provider agreement.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:05"> <META NAME="Description" Content="Administrative Rules 67:16:35:05 Electronic media provider agreement."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:05.&nbsp;&nbsp;Electronic media provider agreement.</b> Providers submitting claims by electronic media must have a signed electronic media agreement with the department before submitting claims.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 4, effective July 16, 1990.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:06 Medical assistance cross-over claim requirements.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:06"> <META NAME="Description" Content="Administrative Rules 67:16:35:06 Medical assistance cross-over claim requirements."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 15 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:"Cambria Math"; panose-1:2 4 5 3 5 4 6 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; text-align:justify; font-size:12.0pt; font-family:"Times New Roman",serif; color:black;} a:link, span.MsoHyperlink {color:blue; text-decoration:underline;} a:visited, span.MsoHyperlinkFollowed {color:#954F72; text-decoration:underline;} .MsoChpDefault {font-size:10.0pt; color:black;} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US link=blue vlink="#954F72"> <div class=WordSection1> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:06.&nbsp;&nbsp;Medical assistance cross-over claim requirements.</b> A cross-over claim may be submitted to the department if the provider's claim to Medicare did not trigger an automatic payment of the deductible or coinsurance. Proof of payment by Medicare must be attached. A cross-over claim must contain the following information:</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;The provider's name and National Provider Identification (NPI) number and taxonomy code;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;The recipient's full name and medical assistance identification number from the recipient's medical assistance identification card;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;Third-party liability information required under chapter 67:16:26;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (4)&nbsp;&nbsp;The date of service;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (5)&nbsp;&nbsp;The place of service;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (6)&nbsp;&nbsp;The provider's usual and customary charge billed to Medicare;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (7)&nbsp;&nbsp;Units of service furnished, if more than one;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (8)&nbsp;&nbsp;The applicable procedure code from the <b>Health Care Common Procedure Coding System</b> (HCPCS), as adopted in &#167;&nbsp;67:16:01:27, or the <b>Current Procedural Terminology</b> (CPT), as adopted in &#167;&nbsp;67:16:01:25;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (9)&nbsp;&nbsp;The amount paid by Medicare plus the Medicare discount or write off amount;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (10)&nbsp;&nbsp;Proof of the deductible or co-insurance, which must be attached;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (11)&nbsp;&nbsp;The amount paid by third-party payers other than Medicare, if any;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (12)&nbsp;&nbsp;The amount originally billed to Medicare; and</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (13)&nbsp;&nbsp;The type of Medicare coverage.</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 4, effective July 16, 1990; 17 SDR 184, effective June 6, 1991; 40 SDR 122, effective January 7, 2014; 43 SDR 80, effective December 5, 2016.</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></p> <p class=MsoNormal>&nbsp;</p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:07 Adjustment/void claims.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:07"> <META NAME="Description" Content="Administrative Rules 67:16:35:07 Adjustment/void claims."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; text-align:justify; font-size:12.0pt; font-family:"Times New Roman","serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:07.&nbsp;&nbsp;Adjustment/void claims.</b> A provider may have a previously paid claim adjusted or voided by completing and submitting a new claim to the Department coded as an adjustment or void. Claim forms may be submitted electronically.</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 4, effective July 16, 1990; 41 SDR 93, effective December 3, 2014.</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></p> <p class=MsoNormal>&nbsp;</p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:08 Requests for reimbursement -- Certification.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:08"> <META NAME="Description" Content="Administrative Rules 67:16:35:08 Requests for reimbursement -- Certification."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:08.&nbsp;&nbsp;Requests for reimbursement -- Certification.</b> The provider or the provider's representative must sign the claim as a certification of the truth and accuracy of the claim. The provider's name, not the name of the facility or business, must be signed using handwriting, typewriter, signature stamp, computer impulse, or other means utilized as a signature. Each claim must indicate the date the form was signed.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 15 SDR 2, effective July 17, 1988; transferred from §&nbsp;67:16:01:07.01, 17 SDR 4, effective July 16, 1990; 23 SDR 38, effective September 26, 1996.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:09 Use of rubber stamps for claim information.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:09"> <META NAME="Description" Content="Administrative Rules 67:16:35:09 Use of rubber stamps for claim information."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:09.&nbsp;&nbsp;Use of rubber stamps for claim information.</b> The use of rubber stamps containing claim information is acceptable only if the imprint is legible.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 4, effective July 16, 1990.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:10 Claim substantiation.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:10"> <META NAME="Description" Content="Administrative Rules 67:16:35:10 Claim substantiation."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:10.&nbsp;&nbsp;Claim substantiation.</b> At the department's request, a provider must furnish information needed to substantiate a claim being processed, a claim being reviewed for determination of payment, or a claim under postpayment review.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 4, effective July 16, 1990; 19 SDR 165, effective May 3, 1993.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:11 Repealed.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:11"> <META NAME="Description" Content="Administrative Rules 67:16:35:11 Repealed."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; text-align:justify; font-size:12.0pt; font-family:"Times New Roman","serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:11.&nbsp;&nbsp;Claim forms and copies.</b> Repealed.</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 4, effective July 16, 1990; repealed, 40 SDR 122, effective January 7, 2014.</p> <p class=MsoNormal>&nbsp;</p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:12 Pended claims.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:12"> <META NAME="Description" Content="Administrative Rules 67:16:35:12 Pended claims."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:12.&nbsp;&nbsp;Pended claims.</b> The department may pend a claim for any of the following general classes of reasons:</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;The claim was submitted with erroneous, incomplete, or missing information;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;The information on the claim does not match the state master recipient or provider eligibility files;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;The claim requires action by the department for medical review, manual pricing, individual requests, late submission exceptions, or utilization review;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (4)&nbsp;&nbsp;The department erroneously entered the claim into the data processing system;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (5)&nbsp;&nbsp;A third-party source exists;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (6)&nbsp;&nbsp;The claim is a possible duplicate of another paid claim;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (7)&nbsp;&nbsp;The claim is suspected of being false;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (8)&nbsp;&nbsp;The claim is incorrect;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (9)&nbsp;&nbsp;The claim is submitted by a provider who is currently being investigated by the Medicaid fraud unit; or</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (10)&nbsp;&nbsp;The claim is submitted by a provider who is currently being reviewed or investigated by the department.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Claims pended under subdivision (9) or (10) of this section remain pended until the investigation or review is completed. Time limits for processing claims do not apply to claims pended under subdivision (9) or (10) of this section.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 184, effective June 6, 1991; 19 SDR 165, effective May 3, 1993.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Cross-References:</b></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Remittance advice, §&nbsp;67:16:35:14;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Timely processing of claims -- Time limitation does not apply to claims from providers under investigation for fraud or abuse, 45 C.F.R. §&nbsp;447.45(d)(4)(iii);</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Payments and obligations to be authorized by law -- Liability to state for unauthorized payments, SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=4-8-2">4-8-2.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:13 Denied claims.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:13"> <META NAME="Description" Content="Administrative Rules 67:16:35:13 Denied claims."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:13.&nbsp;&nbsp;Denied claims.</b> The department may deny a claim for any of the following reasons:</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp; The service claimed was not medically necessary;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;The claim is a duplicate of a prior paid claim;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;Third-party liability exists;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (4)&nbsp;&nbsp;The claim contains data that is logically inconsistent;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (5)&nbsp;&nbsp;The time limit for the submission of a claim has expired;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (6)&nbsp;&nbsp;The provider or recipient of service was not eligible when the service was provided;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (7)&nbsp;&nbsp;The drug is considered less than effective;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (8)&nbsp;&nbsp;The service is considered experimental;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (9)&nbsp;&nbsp;The claim contains erroneous, incomplete, or missing information;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (10)&nbsp;&nbsp;The claim is false or incorrect or violates provisions of this article; or</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (11)&nbsp;&nbsp;The service is incidental to or an integral part of an allowable service.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 184, effective June 6, 1991; 19 SDR 165, effective May 3, 1993.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Cross Reference:</b> Payments and obligations to be authorized by law -- Liability to state for unauthorized payments, SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=4-8-2">4-8-2.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:14 Remittance advice.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:14"> <META NAME="Description" Content="Administrative Rules 67:16:35:14 Remittance advice."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:14.&nbsp;&nbsp;Remittance advice.</b> The provider must reconcile the remittance advice with the patient's records. The department shall send a warrant with the remittance advice when the amount of a check is indicated on the remittance advice. The provider must retain the remittance advice according to §&nbsp;67:16:34:05. Claims to be resubmitted for payment must meet the requirements of §&nbsp;67:16:35:15.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; When the department denies or pends a claim, the remittance advice shall contain the specific reason the claim was denied or pended.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 184, effective June 6, 1991; 19 SDR 165, effective May 3, 1993.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Cross-Reference:</b> Pended claims, §&nbsp;67:16:35:12.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:15 Claim submission and resubmission limits.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:15"> <META NAME="Description" Content="Administrative Rules 67:16:35:15 Claim submission and resubmission limits."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:15.&nbsp;&nbsp;Claim submission and resubmission limits.</b> A participating provider may not submit a claim for a provider who has been excluded or terminated from the medical assistance program or who otherwise does not meet provider requirements in this article.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Claims for medically necessary covered services provided prior to a provider's exclusion or termination may be submitted to the department after the exclusion or termination.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; A provider may not resubmit a claim to the department if the claim has been pended, has already been paid, has been denied because it is not a covered service or is not a medically necessary covered service, or is in violation of this article. The resubmission of such a claim is considered an abuse of the program and may be cause for terminating the provider agreement.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; A previously denied claim may be resubmitted when there is new or additional information which will substantiate the claim or when the previously submitted incorrect data is resubmitted correctly.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 184, effective June 6, 1991; 19 SDR 165, effective May 3, 1993.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Cross-Reference:</b> Duration of agreement, §&nbsp;67:16:33:04.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 67:16:35:16 Application of chapter.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:35:16"> <META NAME="Description" Content="Administrative Rules 67:16:35:16 Application of chapter."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:35:16.&nbsp;&nbsp;Application of chapter.</b> The rules in this chapter apply to all enrolled providers and recipients.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 17 SDR 184, effective June 6, 1991.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html>