67:16:08:09Claim requirements.

A claim for services provided under this chapter must be submitted on a form or in an electronic format that contains the following information: (1) The recipient's full name; (2) The recipient's medical assistance number from the recipient's medical assistance identification card; (3) Third-party liability information required under chapter 67:16:26; (4) Date of service; (5) Place of service; (6) The provider's usual and customary charge. The provider must not subtract other third-party or cost-sharing payments from this charge; (7) The applicable procedure codes for the covered services provided; (8) The units of service furnished, if more than one; and (9) The provider's name and national provider identification number. A separate claim form must be submitted for each recipient.

Source: 17 SDR 4, effective July 16, 1990; 35 SDR 49, effective September 10, 2008.