South Dakota Administrative Rules
Title 67 - Department of Social Services
Article 67:54 - Medical programs administered by Department of Human Services
Chapter 67:54:06 - Assistive daily living services for individuals with quadriplegia
Section 67:54:06:16 - 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 recipient's full name;
(2) The recipient's medical assistance identification number from the recipient's medical identification card;
(3) The third-party liability information required under chapter 67:16:26;
(4) The date of service;
(5) The place of service;
(6) The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge;
(7) The units of service furnished, if more than one, for each procedure;
(8) The applicable procedure codes;
(9) The type of service; and
(10) The provider's name and medical assistance identification number.
A separate claim form must be used for each client.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Note: The HFCA 1500 form substantially meets the requirements of this rule and its content and appearance are acceptable to the department. These 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.
Claims, ch 67:16:35.
