South Dakota Administrative Rules
Title 67 - Department of Social Services
Article 67:16 - Covered medical services
Chapter 67:16:43 - Care management - Medically complex children
Section 67:16:43:09 - Claim requirements
Current through Register Vol. 51, page 43, September 23, 2024
A claim for services provided under this chapter must be submitted on a form which contains the following information:
(1) The child's full name;
(2) The child's medical assistance identification number from the child's medical identification card;
(3) Third-party liability information required under chapter 67:16:26;
(4) Date of service;
(5) The provider's current daily rate. The provider may not subtract other third-party or cost-sharing from this charge;
(6) Units of service furnished, if more than one;
(7) The applicable diagnosis codes adopted in § 67:16:01:26;
(8) The provider's name and National Provider Identification (NPI)number;
(9) Type of admission;
(10) The prior authorization number assigned by the care manager;
(11) The revenue code; and
(12) The type of bill.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Note: The CMS 1450 (UB-04) forms are available for direct purchase through the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402. (202) 783-3238 - pricing desk.
