47:03:09:01. Properly submitted medical bill. A properly
submitted medical bill is a request by a provider for payment of health care
services that meets the following requirements:
(1) Submitted to the
employer according to the applicable reporting and coding standards of the
Centers for Medicare and Medicaid Studies, the National Council for
Prescription Drug Programs, or the American Dental Association; and
(2) Accompanied by
sufficient medical records or reports that the employer can determine the
reasonableness and necessity of the treatment provided.
A submission to a self-insured
employer, insurer, medical bill reviewer, medical case management plan, third
party administrator, claims adjuster, trustee, guarantor, or other entity
having a similar association to the employer is considered submission to all
such entities simultaneously. The employer may waive the requirements of this
section.
Source:
34 SDR 322, effective June 30, 2008.
General
Authority: SDCL 62-4-1.2.
Law
Implemented: SDCL 62-4-1.1, 62-4-1.2.
Note:
The Centers for Medicare and Medicaid Studies publishes its bill processing
requirements at www.cms.hhs.gov/QuarterlyProviderUpdates.
For pharmacy-related bill processing, information is available at NCPDP, Inc.
4201 North 24th Street, Suite 365, Phoenix, AZ 85016-6268, (602)
957-9105. For dental bill processing, information is available at www.ada.org, 211 East Chicago Ave., Chicago, IL
60611-2678, (312) 440-2500.
