ARSD 67:16:28:10. 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 § 67:16:28:04; (8) The units of service furnished, if more than one; and (9) The provider's name and medical assistance identification number. A separate claim form must be used for each recipient.