South Dakota Administrative Rules
Title 67 - Department of Social Services
Article 67:45 - Nursing facility level of care and claims
Chapter 67:45:02 - Nursing facility claims and payments limits
Section 67:45:02:12 - Claim requirements
Current through Register Vol. 50, page 114, March 25, 2024
A claim for services provided under this chapter must be submitted on the CMS 1450 (UB-04) form or in an electronic format that contains the following:
(1) The recipient's full name;
(2) The recipient's medical assistance identification number from the recipient's medical assistance identification card;
(3) Third-party liability information as required under chapter 67:16:26;
(4) Beginning and end dates of service. A provider may only bill for one month at a time;
(5) The number of covered days;
(6) The total charges;
(7) The type of bill;
(8) The provider's name, address, telephone number, and National Provider Identification (NPI) number;
(9) The applicable diagnosis codes adopted in § 67:16:01:26;
(10) The patient status code indicating the patient's status on the final day of service of the billing period; and
(11) The revenue code identifying the specific accommodation, ancillary service, or billing calculation.
A separate claim form must be submitted for each recipient.
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.
