ARSD 67:16:14:14. Claim requirements

A claim for items provided under this chapter must be submitted on a claim 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 number of days for which the item is supplied; (4) The name of the drug; (5) The multiple-source drug override indicator if the brand name is medically necessary; (6) Third-party liability information required under chapter 67:16:26; (7) Date of service; (8) The provider's usual and customary charge or cost, as applicable. The provider may not subtract other third-party or cost-sharing payments from this charge; (9) Units of service furnished; (10) The provider's name and National Provider Number (NPI), or the provider's PHS medical assistance identification number if the claim is for a drug covered under a PHS provider agreement; (11) The prescription number assigned; (12) The national drug code (NDC) number taken from the package or container used in dispensing the prescription. If the drug dispensed does not have an NDC number or is a compounded product, enter "0999-2000-00" on the claim form and further identify the item as a "special attention" item; (13) The metric quantity of the drug dispensed; (14) An indication if the prescription was a refilled prescription or was dispensed as a unit dose; (15) The name or the South Dakota medical assistance provider number of the person prescribing the drug; (16) The provider's National Council of Prescription Drug Providers (NCPDP) number; and (17) The prescribing physician or other licensed practitioner's Drug Enforcement Agency (DEA) number. A claim for a PHS-covered drug must be submitted on a separate claim and may not be combined with a claim for other drugs covered under this chapter even if the provider is the same.