ARSD 67:16:48:13. Claim requirements -- Substance use disorders

A claim for a substance use disorder treatment service provided under this chapter must be submitted to the department on a form or in an electronic format and must contain the following information: (1) The service 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 covered services provided; (8) The applicable diagnosis codes; (9) The units or days of service furnished, if more than one; (10) The provider's name and National Provider Identification number; and (11) The prior authorization number issued to the provider by the division for services that require prior authorization. A separate claim form must be used for each recipient.