67:16:35:13Denied claims.

Section · Administrative Rules of South Dakota · View on sdlegislature.gov ↗

Rulemaking activity

Article 67:15 (LIEAP), Article 67:16 (MS - Transportation) Article 67:18 (Child Support Enforcement), Article 67:42 (Family Foster Homes), Article 67:46 (Economic Assistance)Effective

The department may deny a claim for any of the following reasons: (1) The service claimed was not medically necessary; (2) The claim is a duplicate of a prior paid claim; (3) Third-party liability exists; (4) The claim contains data that is logically inconsistent; (5) The time limit for the submission of a claim has expired; (6) The provider or recipient of service was not eligible when the service was provided; (7) The drug is considered less than effective; (8) The service is considered experimental; (9) The claim contains erroneous, incomplete, or missing information; (10) The claim is false or incorrect or violates provisions of this article; or (11) The service is incidental to or an integral part of an allowable service.

Source: 17 SDR 184, effective June 6, 1991; 19 SDR 165, effective May 3, 1993.

General Authority

SDCL 28-6-1 ↗
Amended by HB1239 (2020) — require the costs of nursing homes to be rebased every five years for purposes o
Amended by HB1229 (2019) — require optional services through Medicaid to be authorized through special appr
Amended by SB30 (2019) — remove certain unnecessary federal references and dates from certain provisions

Law Implemented

SDCL 28-6-1 ↗
Amended by HB1239 (2020) — require the costs of nursing homes to be rebased every five years for purposes o
Amended by HB1229 (2019) — require optional services through Medicaid to be authorized through special appr
Amended by SB30 (2019) — remove certain unnecessary federal references and dates from certain provisions

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