ARSD 67:16:11:19.04. Claim requirements -- Immunizations

A claim for immunization services provided under this chapter must be submitted on a form or in an electronic format that contains the following information: (1) The recipient's full name; (2) The recipient's medical assistance identification number from the recipient's medical assistance identification card; (3) The third-party liability information required under chapter 67:16:26; (4) The date of service; (5) The applicable procedure codes for the covered services provided; and (6) The provider's name and national provider identification number. A separate claim must be submitted for each recipient.