ARSD 67:16:29:11. Claim requirements

A claim for 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 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 this chapter; (8) The units of service furnished, if more than one; (9) The provider's name and National Provider Identification (NPI) number; (10) The ordering provider's NPI number; (11) The prior authorization number issued by the department for services requiring prior authorization; (12) One of the following modifier codes, as applicable, at the end of the procedure code: (a) LL - Lease/rental, when rental is to be applied to the purchase price; (b) NU - New equipment; (c) RP - Replacement and repair; (d) RR - Rental, when medical equipment is to be rented; or (e) UE - Used medical equipment; and (13) Special comments if maintenance and repair services are for nursing facility recipients who own their medical equipment. A separate claim must be submitted for each recipient.