ARSD 67:16:42:13. Claim requirements

A claim for nutritional items and supplies 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) 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 the items and services provided; (8) The units of service furnished, if more than one; (9) The provider's name and National Provider Identification (NPI) number; and (10) If applicable, the prior authorization number issued to the provider by the department. A separate claim form must be submitted for each recipient.