ARSD 67:16:24:06. Claim requirements

A claim for services provided under this chapter must be submitted on a form available from the department or the claim may be electronically transmitted through a system approved by the department. The claim must contain 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) Date of service; (4) As specified in the provider's contract with the department, the provider's rate of payment for the service provided; (5) The units of service furnished, if more than one; and (6) The provider's name and medical assistance identification number. A separate claim form must be used for each recipient.