ARSD 67:16:25:12.01. Claim requirements -- Community transportation services

A claim for community transportation 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) Date of service; (4) The point of origin and the destination of the recipient being transported; (5) The provider's usual and customary charge; (6) The applicable procedure codes for the services provided; (7) The units of service furnished, if more than one; and (8) The provider's name and National Provider Identification (NPI) number. A separate claim must be submitted for each recipient.