67:16:46:06Claim requirements.

A claim submitted under this chapter must be submitted at the provider's usual and customary charge and must contain the applicable procedure codes contained in § 67:16:46:05. The claim for services must be submitted on a form 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 may not subtract other third-party or cost-sharing payments from this charge; (7) The procedure codes for services covered under § 67:16:46:05; (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 used for each recipient.

Source: 28 SDR 84, effective December 20, 2001; 40 SDR 122, effective January 7, 2014.