ARSD 67:16:11:17. Claim requirements -- Orthodontia services

A claim for orthodontia services provided in 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 payments from this charge; (7) The applicable procedure codes for the covered services provided; (8) The applicable diagnosis codes; (9) The units of service furnished, if more than one; (10) The provider's name and National Provider Identification number; and (11) The prior authorization number. A separate claim form must be submitted for each recipient.