South Dakota Administrative Rules
Title 67 - Department of Social Services
Article 67:16 - Covered medical services
Chapter 67:16:26 - Third-party liability
Section 67:16:26:05 - Provider must collect from third-party source before submitting claim to department - Medical assistance program payer of last resort - Payment provision

Because the medical assistance program is the payer of last resort, a provider must pursue the availability of third-party payment sources whether or not the sources are identified by the department.

The provider must be able to document the provider's pursuit of the availability of a third-party payment source, except for claims listed in § 67:16:26:07.02. The documentation must be maintained in the recipient's records. Documentation may include a signed statement by the recipient informing the provider of all third-party payment sources.

Once the provider has identified a third-party payment source, the provider must submit a completed claim for payment of services to the third-party source before requesting payment from the department. Except for an electronic claim, if a claim is subsequently submitted to the department for payment, evidence of third-party payment or rejection must accompany the claim. For an electronic claim, the provider must maintain and submit to the department on request evidence of the third-party payment or rejection. The provider is eligible to receive the recipient's third party liability responsibility amount or the amount allowed under the department's payment schedule less the third-party liability amount, whichever is less.

The department may not pay for any service that has been denied by the third-party liability source as not meeting the requirements for submitting a claim.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

Department determination of possible existence of third-party source -- Claim denial, § 67:16:26:07.

Certain claims eligible for payment before third-party benefits recovered -- Department to pursue reimbursement, § 67:16:26:07.02.

Records, ch 67:16:34.