ARSD 67:16:47:12. 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 individual’s full name and identification number as they appear on the individual’s medical assistance identification card; (2) Third-party liability information required under chapter 67:16:26; (3) The date of service; (4) The place of service; (5) The type of service; (6) The provider’s usual and customary charge. The provider may not subtract other third-party payments from this charge; (7) The units of service furnished, if more than one; (8) The procedure code T2048; (9) The provider’s name, address, and telephone number; (10) The facility’s medical assistance identification number; (11) The signature of the provider or provider’s representative and the date of the signature; and (12) The prior authorization number issued by the department. A separate claim must be submitted for each recipient.