67:16:09:08Claim 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 service 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 required under chapter 67:16:26; (4) Date of service; (5) 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 applicable procedure codes for services provided; (8) The applicable diagnosis codes; (9) The units of service furnished, if more than one; and (10) The provider's name and National Provider Identification number. A separate form must be submitted for each recipient.

Source: 17 SDR 4, effective July 16, 1990; 18 SDR 78, effective November 4, 1991; 19 SDR 26, effective August 23, 1992; 19 SDR 128, effective March 11, 1993; 19 SDR 160, effective April 26, 1993; 20 SDR 149, effective March 21, 1994; 21 SDR 183, effective April 30, 1995; 33 SDR 137, effective March 7, 2007; 42 SDR 51, effective October 13, 2015; 52 SDR 126, effective July 1, 2026.