ARSD 67:16:02:17. Claim 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) Units of service furnished, if more than one; (8) The applicable procedure codes; (9) The applicable diagnosis codes; (10) The provider's name and National Provider Identification number; (11) If the provider is a group provider, the National Provider Identification number of the physician or applicable enrolled provider who provided the care or service; (12) Type of service; and (13) The modifier code described in § 67:16:02:03.03, as applicable. A separate claim must be submitted for each recipient.