ARSD 67:16:13:09. Claim requirements

A claim for services provided under this chapter must be submitted on a form 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) The applicable procedure codes for services covered under this chapter; (8) The applicable diagnosis codes; (9) The units of service furnished, if more than one; (10) The billing provider's name and National Provider Identification (NPI) number; and (11) The NPI number of the servicing provider who provided or supervised the care or service. A separate claim form must be used for each recipient.