ARSD 67:16:41:13. 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 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 from this charge; (7) Units of service furnished, if more than one; (8) The applicable procedure codes contained in § 67:16:41:09; (9) The applicable diagnosis codes; (10) The provider's name and National Provider Identification number; and (11) Type of service provided.