ARSD 67:16:25:10. Claim requirements -- Ambulance

A claim for air or ground ambulance services provided under 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 point of origin and the destination of the recipient being transported; (7) The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge; (8) The applicable procedure codes for the services provided; (9) The applicable diagnosis codes or the reason the recipient required the type of transportation provided; (10) The units of service furnished, if more than one; (11) The provider's name and National Provider Identification number; and (12) The reason for any additional attendant provided. A separate claim must be submitted for each recipient.