ARSD 67:16:43:09. Claim requirements

A claim for services provided under this chapter must be submitted on a form that contains the following information: (1) The child's full name; (2) The child's medical assistance identification number from the child's medical identification card; (3) Third-party liability information required under chapter 67:16:26; (4) Date of service; (5) The provider's current daily rate. The provider may not subtract other third-party or cost-sharing from this charge; (6) Units of service furnished, if more than one; (7) The applicable diagnosis codes; (8) The provider's name and National Provider Identification number; (9) Type of admission; (10) The prior authorization number assigned by the care manager; (11) The revenue code; and (12) The type of bill.