ARSD 67:16:37:15. Claim requirements

A claim for services provided under this chapter must be submitted on a form which 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) The third-party liability information required under chapter 67:16:26; (4) The date of service; (5) The 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 procedure codes designated for services covered under this chapter, listed on the department's billing guidance website; (8) The units of service furnished, if more than one; (9) The billing provider's name and National Provider Identification (NPI) number; and (10) The National Provider Identification (NPI) number of the servicing provider who provided or supervised the care or service. A separate claim form must be used for each recipient.